Pulmonary and critical care surg

Question 1

sudden onset wheezing in a child that is unresponsive to albuterol, CXR doesnt show a foreign body. most likely diagnosis?

Answer 1

foreign body aspiration. most objects are radiolucent and therefore not identified on xray!!

decreased breath sounds, hyperresonnance may occur

Question 2

fever, dyspnea, diffuse interstitial infiltrates on CXR, and small pleural effusions. 3 months post bilateral lung transplant for CF. patient on trimethorprim-sulfamethoxazole. most likely diagnosis?

Answer 2

CMV pneumonitis!!! = occurs within 1st year of lung transplant

pneumocystis similar presentation but more indolent over weeks and patient is on propylaxis.

contrast to Aspergillosis = chronic asthma in patients eg with CF pre transplant. POST transplant = necrotising aspergillosis causing hemoptysis and halo sign on CXR

NOT chronic rejection as this occurs after a year and causes progressive fibrosis, obstruction and wheezing. not interstitial pneumonitis and crackles. CMV is RF

Question 3

5 days post resection for colon cancer. chest pain, dyspnea, sinus tachycardia. ECG shows right basal atelectasis. patient on prophylactic LMWH. next step in management?

Answer 3

CT pulmonary angiography!!!

prophylactic LMWH does not entirely eliminate the risk.

recent surgery, cancer, tachycardia -> wells score points to PE

yes postoperative atelectasis is common in setting of pain post surgery and positive-pressure ventilation sometimes used to help, however atelectasis alone does not typically cause chest pain. just have to rule p.e out first

wells score <4 -> P.E unlikely. do a ddimer, and if less than or equal to 500, excludes DVT.

Question 4

patient with rhumatoid arthritis but seems to be well controlled because joint deformities with no swelling and minimal tenderness. experiencing shoulder pain radiating to forearm. strong smoking history. Horners syndrome.

next step in management?
most likely diagnosis?

Answer 4

CXR!!

superior pulmonary sulcus tumour!

pain and weakness/atrophy muscles in ulnar distribution eg intrinsic hand muscles.

Question 5

motor vehicle collision. hemopnemothorax requiring chest tube placement. and NG tube. days later patient still breathless and CXR shows NG tube is in the stomach which is abnormally located in the left hemithorax of the chest. most likely diagnosis?

Answer 5

diaphragmatic injury!!! (diaphragmatic hernia)

Question 6

fell and hit left chest against coffee table. left lung base dull to percussion with diminished sounds. left chest pain worse with inspiration. BP 88/50, pulse 122. most likely cause of injury?

Answer 6

intercostal vessel injury!!!!

hypovolemic shock in blunt chest trauma concerning for intrathoracic hemorrhage -> and rib fractures! with intercostal vessel injury!! is most common cause of intrathoracic hemorrhage!!!!

NOT bronchial rupture = crepitus!!, large pneumothorax and hyperresonance not dullness

NOT diaphragm dysfunction eg trauma or nerve injury = tachypnea, dyspnea, and unilateral decreased breath sounds but not shock

NOT aortic tear as more severe mechanism. ascending aortic tear = acs, neuro deficits, tamponade.

Question 7

right pneumothorax with deviation. chest tube placed. but there is a persistent large air leak despite adequate seal. next step in management?

Answer 7

bronchoscopy!!!!

suggests continuous air accumulation from tracheobronchial injury!! and bronchoscopy allows you to have a good look at the tracheobronchial tree

NOT insertion of additional tube - only used if the existing one is inadequate eg limiting ability to drain as small diameter

NOT talc pleurodesis = obliteration of pleural space to prevent recurrent pleural effusions (eg malignant effusions.) or pneumothorax in COPD. not used in primary treatment

NOT repositioning tube as CXR showed it wa in right place

NOT increase PEEP in mechanical ventilation as patient is no longer hypoxemic and this is used for conditions affecting alevoli not large airways like tracheobronchial tree.

Question 8

displaced fractures of ribs 9-12 can injure intrabdominal organs including spleen. next best step in management?

Answer 8

CT abdomen!!

irritation of diaphragm can also cause referred pain to shoulder.

Question 9

Solid pulmonary nodules >0.8cm require management eg excision or surveillance with ct. What factors will point you towards surgical excision if present?

Answer 9

advanced patient age, smoking history, family history of lung cancer, large size!. note size > 2cm = 50% probability of maligancy and you only need a FIVE 5% probability of malignancy for excision or biopsy. in question, the size was 2cm.

Question 10

long standing productive cough particularly while eating!!, yellow sputum. fever!! night sweats, weight loss!!!. leukocytosis. right lower lobe solitary cavitating lesion. no recent sick contacts or travel. history of parkinsons disease. 5 year smoking history. most likely diagnosis?

Answer 10

Lung abscess!!!!!

Parkinsons disease points to swallowing dysfunction!!! including coughing whilst eating!

also seen in patients with periods of impaired consciousness eg siezure disorder, alcohol or drug abuse

NOT lung cancer - as fever, swallowing dysunction and productive cough rather than dry cough point away from this.

NOT TB less likely due to presence of swallowing dysfunction

Question 11

a motor vehicle collision can cause blunt abdominal thoracic trauma. If CXR findings of bowel loops in chest region and mediastinal shift to opposite side, this signals diaphragmatic rupture!!!

next step in management?

Answer 11

CT scan of chest and abdomen!! = diagnostic

*note multiple air filled loops points to bowels and not penumothorax

Question 12

patient with COPD, sudden onset severe dyspnea and and right sided chest pain. decreased tactile fremitus on the right. trachea is midline. most likely underlying mechanism of condition?

Answer 12

rupture of an apical alveolar bleb!!!-> most common cause in COPD -> patient had secondary spontaneous pneumothorax

NOT atelectasis as typically would be history of foreign body inhalation, malignancy or severe pneumonia and it typically causes tracheal deviation towards the collapsed lung.

Question 13

1. sepsis/distributive shock = Low CVP central venous pressure (right sided pre-load) and Low PCWP pulmonary capillary wedge pressure (left sided pre-load)
2. hypovolemic shock is same as above

3.. LVF can occur from MI and causes cardiogenic shock = HIGH CVP and PCWP, low CO

4. Obstructive shock = pre pulmonary typically due to massive PE or tension pneumothorax!!!. HIGH CVP, low PCWP, low cardiac output. post pulmonary obstructive shock eg aortic dissection or severe aortic stenosis causes same findings as in cardiogenic shock

Question 14

patient admitted for sepsis in setting of pneumonia, on venitlator. sudden onset hypotension and tachycardia,. bp 82/54. pulse 120. CVP is elevated. PCWP is 6 so just at the bottom end of normal. most likely cause of patients shock?

Answer 14

pulmonary embolism

Question 15

exstensive air leakage from tracheobronchial tree and lung compression from increased intrapleural pressure is seen in pneumothorax

Question 16

a case of post operative atelectasis is described - decreased breath sounds in right lung base.

What would be the ABG findings? Ph? PaO2? PaCo2?

Answer 16

hypoxemia!!

and respiratory alkalosis due to hyperventilation!!!

low PaC02, low PaO2. high PH.

Question 17

preventing post-operative pulmonary complications eg atelectais, pneumonia

Answer 17

symptomatic control of underlying lung disease
smoking cesation. FOUR to 8 weeks before surgery
pain control, deep breathing exercises, incentive spirometry

Question 18

stabbed in chest. BP 90/50.! pulse 124. in respiratory distress. breath sounds absent!!! on right side and neck veins distended. patient becomes obtunded. heart sounds normal. diagnosis?
next step in management?

Answer 18

Tension pneumothorax!!!!

features: diminished breath sounds!!!!, decreased tactile vocal fremitus. hypotension (sometimes) hyperresonance

Hypotension due to high intrathoracic pressure that compresses vena cava and impedes cardiac return.

management = needle thoracostomy!!! for decompression

NOT emergent department thoracotomy as this is used in trauma patients with witnessed or imminent cardiac arrest - > open cardiac massage, aortic clamping

Question 19

chemical pneumonitis and aspiration pneumonia can both occur following aspiration when a patient is sedated for surgery. distinguish characteristics of the two?

Answer 19

chemical pneumonitis = cough, dyspnea, hypoxemia, infiltrates, crackles wheezes. occurs within minutes or hours = spontaneous resolution!!!

pneumonia = fever! cough with putrid putum!! occurs after several days to weeks and requires antibiotics.

Question 20

Treatment for idiopathic pulmonary fibrosis?

Answer 20

antifibrotic therapy!!!! = perfenidone, nintedanib

NOT steroids or immunosuppression

Question 21

mechanical ventilation has risk of which pulmonary complication?

Answer 21

pneumothorax - decreased breath sounds. contrast p.e. which doesnt affect breath sounds

not right mainstem bronchus intubation as this would cause decreased breath sounds in the left unventilated lung, rather than the right lung as seen in patient

Question 22

22 YO man. no pmhx. spontaneous small apical pneumothorax (<2 cm). dyspnea and chest pain but vitals stable. spo2 98%

first step in management?

Answer 22

oxygen supplementation!!! (regardless of o2 level)!! + observation

if larger = needle aspiration or chest tube.

Question 23

hemoptysis management?

Answer 23

massive hemoptysis: (600ml/24hr or 100ml/hr)
intubate to secure airway
place with bleeding lung in left lateral position
bronchoscopy!!!! to localize bleeding site

mild to moderate:
follow up CXR with CT scan!!

FFP only given if coagulopathy identified as the cause

Question 24

most important first step in rib fracture management to prevent complcations?

Answer 24

adequate analgesia!!

Rib fractures usually heal on their own without surgery. indications for surgery = flail chest, significant chest deformities

Question 25

hemicolectomy under anaesthesia!. significant smoking history! 3 days later, hypoxemia, dullness to percussion and absent breath sounds on left side of chest. CXR shows total opacification of left side of chest and mediastinal shift towards this side. most likely cause of the pulmonary findings?

Answer 25

bronchial mucus plug!! - can lead to large volume atelectasis! NOT a large pleural effusion as mediastinum will be shifted away from and not towards the lesion not multilobar pneumonia as it can cause total white out of hemithorax as well, but mediastinum wont shift and fever and cough would be expected.

Question 26

diffuse pulmonary edema causes large intrapulmonary shunt, increased a-a gradient and hypoxemia that doesnt correct with extra 02. search the values/effect for other causes of hypoxemia. pitcure in ipad

Question 27

sepsis due to ascending cholangitis and diffuse wet crackles and fluffy opacities on CXR (Pulmonary edema). sinus tachy, normal troponin. bedside TTE shows hyperdynamic left ventricular contractions and trace mitral regurgitation. most likely diagnosis? next step in management?

Answer 27

ARDS! occurs within 1 week of insult-> pneumonia, pancreatitis trauma are other risk factors. no further testing!! as cardiac causes and volume overload excluded. normal JVP and normal LVF rule out volume overload and cardiac causes of pulmonary edema. Trace mitral regurg is normal!! and not an indication for TEE

Question 28

penetrating chest stab wound. initially managed by tube thoracostomy (chest tube) with 2,000ml of blood. next step in management?

Answer 28

emergent thoracotomy!!! as blood loss is >1,500ml!!! (massive hemothorax!!!) other indications = >200ml/hr blood loss for > 2 hours, or continuous need for blood transfusions to maintain hemodynamic stability. penetrating trauma + shock = hemorrhage until otherwise proven

Question 29

lung abscess treatment

Answer 29

ampicillin sulbactam! or a carbapenem drug or alcohol use = RF

Question 30

76 YO man 2 weeks cough, SOB, right sided chest pain and fever history of alzheimers dementia leukocytosis pleural effusion noted which is turbid and foul smelling diagnosis? cause?

Answer 30

Empyema!! (aspiration pneumonia in setting of alzheimers -> pleural effusion -> empyema) oral streptococci and anaerobes!! / anaerobic oral flora pneumonia symptoms + weight loss + leukocytosis/thrombocytosis + turbid pleural fluid = empyema foul smelling!! = ANAerobic empyema not TB as rare cause of empyema and is aerobic pseudomonas, staph and strep can cause empyemas but all aerobic!!

Question 31

23 YO. hemoptysis. recurrent epistaxis since childhood. continuous bruit in right infrascapular region (pulmonary bruit) diagnosis?

Answer 31

AVMS!! = HHT brain = CVA, Brain abscess due to embolization from pulmonary AVM mucocutaneous = nosebleeds, telangiectasia lung = pulmonary avm/hemoptysis, PAH/Right sided HF GI = chronic GI bleed, Liver: portal hypertension, high output HF

Question 32

fracture of femur after fall from ladder when having a siezure. patient presents with bilateral scattered ground glass opacities on imaging. patient is disoriented (neurologic dysfunction) and hypoxemic (respiratory distress). most likely diagnosis?

Answer 32

fat embolism!!! rash is present in less than half of cases!!! not pulmonary contusion as this just causes pulmonary edema at the site of the lesion.,

Question 33

pnemonia can cause small effusions that resolve with antibiotics (uncomplicated effusions) they can also cause complicated effusions or empyemas where bacteria invades pleural space. treated with antibiotics PLUS chest tube drainage!!! signs of emyema?

Answer 33

pleural fluid: 1. pH <7.2!!. low ph!!! 2. Glucose <60!. low glucose!!!! 3. WBCs > 50,000 4. LD >1,000 6. gram stain and culture MAY be positive moderate to large effusion vs small to moderate in an uncomplicated effusion

Question 34

productive cough with phlegm, SOB, fever pleuritic chest pain. CXR shows LARGE left sided consolidation patient has HIV most likely diagnosis?

Answer 34

Empyema!!! from initial pneumonia HIV RF for emypema development as is other immunocompromise eg transplant NOT PCP as this causes bilateral aveolar infilitrates with perihilar predominance = bilateral fuzziness

Question 35

acute pyelonephritis. Central venous catheter placed for IV antibiotics. sudden onset dyspnea + acute decompensation develops -> low BP, tachycardia, followed by PEA (cardiac arrest). breath sounds normal, trachea midline. most likely diagnosis?

Answer 35

Venous air embolism. symptoms due to VAE causing right ventricular outflow tract obstruction or obstructing pulmonary arterioles management = left position!!, high flow oxygen risk factors: central venous catheter manipulation, neurosurgeries, pulmonary barotrauma, trauma normal breath sounds no crqackles - not ards cardiac tamponade causes shock but not hypoxemia

Question 36

dyspnea for 1 month, 5 years after lung transplant. on stable immunosuppressive therapy. no new changes on CXR. BAL normal (need to do to rule out infeciton) most likely diagnosis? management? management of acute lung transplant rejection <6months

Answer 36

bronchiolitis obliterans! = manifestation of chronic lung transplant rejection. usually 5 years post. dsypnea, cough, obstructive pattern supportive, repeat transplant acute = steroids not hypersensitivity pneumonitis or pulmonary fibrosis = restrictive pattern emphysema unlikely, non smoker

Question 37

CABG. patient now has, dyspnea, orthopnea and paradoxical movement of chest and abdomen!!! most likely diagnosis?

Answer 37

phrenic nerve injury! cardiac surgery is RF, Radiation, tumor

Question 38

post surgery, sudden onset fall/syncope hypotension, signs of acute right heart strain eg new rught bundle branch block, elevated JVP. most likely diagnosis? complication?

Answer 38

Massive PE untreated RV obstruction -> brain hypoperfusion -> dilated pupils, confusion, unintelligible speech. bradycardia and cardiac arrest

Question 39

most common cancer of lungs in non young smokers? causes obstruction (dyspnea, wheezing, post obstructive pneumonia), hemoptysis!! CT shows mass with endobronchial component

Answer 39

bronchial carcinoid tumor

Question 40

MV accident. Trauma work up is negative for major injuries. but bruising and severe pain over right side of chest. over next 6 hours. worsening tachycardia and tachypnea. breath sounds decreased on right side. patchy infiltrates in right middle and lower lobe most likely diagnosis?

Answer 40

Pulmonary contusion!!! - can also be bilateral, Rales may be heard. not ARDS which can occur after trauma as infilitrates will be BILATERAL. and onset is at least 24 hours after injurt not ft embolism as no broken bone and typically long bone or pelvic fracture and manifests at least 24 hours after incident/ + 50% neurologic changes pain control, oxygen, incentive spirometry/chest PT

Question 41

surgery for stab wound and bleeding in abdomen. goes well. after anesthesia mechanical ventilation etc. 1 hour after end of all of this and procedure. blood pressure, heart rate, respirations all drop most likely cause?

Answer 41

Delayed emergence from anaesthesia!!! = failure to return to consciousness after 60!! minutes of last anaesthetic!! presents with respiratory failure (low pH, elevated pCO2, low PO2), bradypnea, bradycardia NOT Post-extubation laryngeal edema as patient will be striderous with fast heart rate not slow one NOT cardiogenic pulmonary edema as can be precipitated by cardiogenic shock in surgery in people with risk factors -> but elevated JVP, tachycardia present along with hypotension.

Question 42

post surgery, how do you tell the difference between hypoxemia due to hypoventilation vs hypoxemia due to atelectasis

Answer 42

hypoventilation = normal A-A gradient atelectasis = elevated a-a gradient!! due to shunting in areas with collapsed alveoli

Question 43

chest trauma. tracheal deviation, decreased breath sounds and dullness to percussion. most likely diagnosis?

Answer 43

hemothorax!!!! tension pneumothorax would cause hyperresonnance!!

Question 44

accident. respiratory distress. breath sounds diminished bilaterally. bilaterall chest tubes placed. patient develops respiratory failure requirng mechanical ventilation. CXR shows MULTIPLE rib fractures and infilitrates in keeping with pulmonary contusion. most likely diagnosis?

Answer 44

Flail chest!!

Question 45

accident, abdominal distension and signs of hypovolemic shock -> small left ventricular cavity volume with ejection fraction of 75% dilated left ventricle with apical hypokenesis and engorgement of the inferior vena cava -> cardiogenic shock RV dilatation and hypokenesis -> massive PE

Question 46

what are the best predictors of postoperative outcome following lung resections?

Answer 46

FEV1!! and Diffusion capacity of lung for carbon monoxide DLCO!!!

Question 47

1 hour after colonic resection. 57 yo woman is tachypneic and agitated. Pulse 120. ABG shows ph 7.25, CO2 of 60, and 02 of 70. So essentkally patient is experiencing hypoxemic and hypercapnic respiratory failure. Next step in management?

Answer 47

Intubation!!! Not heparin as this would only be considered later after intubation if it is deemed to be the cause of respiratory failure. But history more suggestive of peri-operative hypoventilation as the cause.

Question 48

Six days after resection of rectum for CANCER. Dyspneic, and tachycardic. anxious with diaphoresis. Chest and heart exam and leg exam clear. Most likely cause?

Answer 48

PE!!!!! - particulary with history of malignancy. MI less likely as no cardiac history and no current signs of chest pain. Question stem would likely say, he underwent coronary angiography with stent placement 2 years ago. Or some other cardiac history!!! And operation may be something like gastrectomy Both can have diaphoresis!!

Question 49

57 with TB case many years ago. Presents with hemoptysis. CXR 3cm cavity in left upper lobe of lung with round 2cm mass in lumen. Most likely cause of hemoptysis?

Answer 49

Aspergilloma!!! It forms in pre-existing cavities from old disease -> lung cancers do not

Question 50

Post surgery Hypoxemic hypercapnic respiratory status = CPAP first -> then BIPAP if insufficient -> then intubation as last resort

Question 51

Following a difficult intubation with aspiration, what factor is most predictive of severity of the resulting aspiration pneumonia??

Answer 51

Volume of aspirated fluid!!!!

Question 52

As physician Watches, there is an expanding neck hematoma at the level of the thyroid cartílage. Next step in management?

Answer 52

Endotracheal intubation!!! In cases of expanding hematoma of neck, cricothyroidotomy and tracheostomy may be difficult or impossible due to location. Moreover, you only try these if endotracheal intubation is unsuccessful