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Terms in this set (154)

Topic

Pulmonary Medicine

Answer

C. Assist/control mode, rate 12/min, tidal volume 700 cc, peak flow 80 L/min

Explanation

We all recognize that the hemodynamic demise in this patient was from dynamic hyperinflation and the creation of auto-PEEP. Just think of air trapping and breath "stacking." This patient's underlying problem is expiratory airflow obstruction. So, what did the emergency department doctor do? In an effort to immediately reverse the acute hypercapnic respiratory failure, he hyperventilated the patient and provided a large tidal volume at a low peak flow rate. (Peak flow determines how fast the gas is delivered for each breath—a higher peak flow results in the breath being delivered quickly [short inspiratory time], allowing for a longer expiratory phase.) This patient could not possibly have had enough time to empty his lungs with each breath. Ultimately, he builds up such a large pressure in his chest (auto-PEEP) that blood flow return is compromised and hypotension ensues. In removing the patient from mechanical ventilation, you allowed the trapped gas to be released and hemodynamic stability returned. While it is tempting to leave the patient on a T-bar without any positive pressure, be assured that he will quickly tire and have a respiratory arrest.

Therefore, you return the patient to mechanical ventilation (assist/control mode is as good as any) with the understanding that you want a tidal volume of 5-10 mL/kg, a high peak flow rate, and a lower respiratory rate (8-14). Even without sophisticated monitoring, you should be able to see that you are not trapping air by auscultating the lungs through a few respiratory cycles and see that the patient has finished his expiration phase before the next breath by the ventilator is delivered. Recognize that this method of ventilating the patient may not fully correct his respiratory acidosis. That's OK; a moderate amount of respiratory acidosis is well tolerated (permissive hypercapnia), so aim to get a pH > 7.20 as your initial goal and let the bronchodilators, steroids, etc., start to work.
Three dishwashers started working at 8:30 a.m. By 1:00 p.m., 11 workers were involved in washing the dishes since there was a huge banquet the previous night, leaving lots of dirty dishes. The dishwashing procedures consisted of:

Pre-rinsing the dirty dishes by hand in a water tank.
Washing the pre-rinsed dishes in the automatic dishwasher.
Draining the washed dishes and placing them in cupboards.
Starting around 2:00 p.m., workers began complaining of such symptoms as headaches and dizziness. By 2:30 p.m., all workers showed the same symptoms. Two seriously affected workers were taken to a local hospital by ambulance; the other 9 workers were also eventually taken to the hospital for treatment.

One of the workers arriving in the emergency department is a 54-year-old woman whose last memory was washing asparagus off a plate. The next thing she remembers was riding in the ambulance.

PAST MEDICAL HISTORY: Peptic ulcer disease, fibromyalgia
MEDICATIONS:
Unknown anxiolytic, estrogen
FAMILY HISTORY:
Unknown
SOCIAL HISTORY: Divorced; lives with her boyfriend in a trailer park; smokes 3 ppd; drinks a 6-pack of beer daily
ROS:
Positives: Headache; dizziness; weakness; nausea; difficulty concentrating; dyspnea; visual changes
PHYSICAL EXAMINATION: BP 126/91, HR 86, RR 30, T 98.8° F
MS: Oriented to name only; speech without dysarthria; 2/3 recall at 5 minutes
General: Erythema to face and trunk
HEENT: PERRLA, EOMI,
Throat clear
Neck: No masses
Heart: RRR without murmurs
Lungs: CTA
Abdomen: +BS, soft, nontender
Neuro: CN grossly intact; reflexes equal and symmetrical
Motor: Full strength throughout with normal muscle tone and bulk
Sensory: Unremarkable
ABG: 7.41/30/370 with O2 Sat 98% on 100% FiO2; carboxyhemoglobin level is 26%
Which of the following is the most likely diagnosis based on the epidemiology of multiple people being ill and this woman's ABG results?
a) Allergic reaction to dishwasher detergent
b) Meningococcemia
c) Influenza A outbreak
d) Carbon monoxide poisoning
e) Asthma
Pulmonary Medicine

Answer

D. Carbon monoxide poisoning

Explanation

All of the workers were diagnosed as suffering from carbon monoxide poisoning. CO has been called the silent killer and is the cause of approximately 5,000 deaths annually, with 2 to 5 times that number requiring treatment. Even with treatment, the devastating sequelae that can accompany CO poisoning can be life-changing. These include chorea, rigidity, dementia, myoclonus, impaired sensory function, seizures, and gait dysfunction. There can also be permanent cardiac damage due to the hypoxia involved in the poisoning process.

CO is an odorless, colorless, and tasteless gas that results from incomplete combustion of fuels (i.e., coal, wood, gasoline). Once inhaled, it binds quickly and tightly to the hemoglobin (Hgb) and crowds out the oxygen; studies have shown CO can bind 200 times stronger than oxygen. Since the Hgb can no longer carry the oxygen, the patient becomes hypoxemic and anoxic. Also, the CO binds with myoglobin in the muscles and interferes with cellular metabolism, causing metabolic acidosis.

Normal carboxyhemoglobin (HbCO) levels are 0-3% for nonsmokers and 3-8% for smokers. A level of 10-20% causes headaches, nausea, vomiting, and dyspnea. A level of 30-40% causes severe headaches, syncope, and tachyarrhythmias. Levels greater than 40% cause Cheyne-Stokes respiration or respiratory failure, seizures, unconsciousness, permanent brain damage, cardiac arrest, and even death.

Because of the vagueness of the symptoms and their similarity to flu-like symptoms (nausea, vomiting, dizziness, headache, etc.), CO poisoning is often misdiagnosed. Also, even if HbCO is present, it cannot be diagnosed with a simple pulse oximetry device—because the displayed saturation level equals the sum of the oxyhemoglobin and carboxyhemoglobin.

So if you suspect a patient has CO poisoning, what should you do? First and foremost, the patient needs high-flow, high-concentration O2, preferably a non-rebreather mask at 15 liters per minute, as well as a large bore IV. Prepare for blood draws (ABG, CBC, electrolytes, CPK, lactate, and carboxyhemoglobin). A urine sample is also useful to rule out rhabdomyolysis (cardiac muscle breakdown secondary to the myoglobin damage from CO). Other treatment modalities may include a CXR, cardiac monitoring, and possibly mannitol to help decrease the cerebral edema accompanying the CO poisoning. Finally, probably the most effective treatment is transfer of the patient to a hyperbaric oxygen unit (HBO). This is clearly indicated when the patient is very symptomatic and/or the HbCO is 25% or greater.
An 80-year-old male is admitted to the hospital with dyspnea and a large right-sided pleural effusion. He is afebrile, complains of a cough that is productive of whitish-clear sputum and reports about a 10-lb. weight loss over the previous 6 months. He denies fever, chills, night sweats, hemoptysis, or chest pain. He has a 50-pack/year history of smoking but quit recently as a 50th anniversary present for his wife. He worked as an accountant and worked in the Brooklyn Naval Yard in World War II but denies any asbestos exposure.

On physical exam he is noted to be afebrile, without adenopathy or skin lesions. Breath sounds are diminished at the right side, and he has dullness to percussion posteriorly to the inferior border of the scapula. There is no clubbing, cyanosis, or edema; his nails and fingertips on his right hand are discolored from nicotine.

CBC: WBC count of 5,000 with 50% neutrophils, 3% bands, 24% lymphs, 17% monocytes, and 6% eosinophils

Serum chemistries indicate: Glucose 84 mg/dL; protein 7.8 g/dL; LDH 162 U/L

Review of the chest x-rays (PA, lateral, decubitus) shows a large, free-flowing effusion with no discernible underlying lung or mediastinal pathology.

Sputum Gram stain has a few WBCs, no organisms
Sputum cytology: Negative for malignant cells

You perform a right-sided thoracentesis and remove almost 1 liter of dark, straw-colored fluid. Pleural fluid is sent for routine studies:

Cell count:
RBCs 8100μL
WBC 3600/μL
Differential:
88% lymphocytes
1% neutrophils
11% monocytes
Fluid Chemistries:
Glucose 45 mg/dL
Protein 5.9 mg/dL
LDH 332 U/L
Cytology: Negative
Which of the following is the most likely etiology of this patient's pleural effusion?
a) Lymphoma
b) Bronchogenic carcinoma
c) Tuberculosis
d) Malignant mesothelioma
e) Parapneumonic effusion
Topic

Pulmonary Medicine

Answer

B. Perform PFTs with a flow-volume loop.

Explanation

This young patient has an illness script consistent with asthma: reversible airway obstruction during exercise. The first step in diagnosis of asthma is to document reversibility of the obstruction with pulmonary function studies. Some form of pulmonary function testing should always be your first step in diagnosing asthma. The methacholine challenge is used to diagnose asthma in asymptomatic patients with normal spirometry but is not 100% sensitive; therefore, usually most recommend exercising the patient and then seeing if they have a fall in FEV 1 (this was not one of the choices here but would be a good alternative in someone with classic symptoms of EIB—which his symptoms are not classic). He could have exercise-induced bronchospasm (EIB), but he complains of wheezing that begins during exercise and is prolonged. EIB usually is associated with bronchodilation during exercise and bronchoconstriction after, such that patients complain of post-exercise coughing and/or wheezing. Usually, EIB symptoms will resolve within 15-60 minutes. He could have an upper airway fixed obstruction or some form of diaphragm paralysis as a result of Guillain-Barré, but most cases of Guillain-Barré recover completely. And this patient functions very well until the peak of exercise, suggesting his diaphragm and upper airways function normally. A flow-volume loop will also provide additional information regarding the upper airway that would help diagnose vocal cord dysfunction, benign adenomas, or fixed airway obstructions as alternate causes of wheezing. Patients who wheeze daily with exertion may have true asthma, not EIB, and they benefit from long-term control therapy as opposed to simply pre-exercise medications.
A 59-year-old man is seen in follow-up. He was initially evaluated for cavitating pulmonary nodules. He has a history of severe, deforming rheumatoid arthritis for 20 years that has required surgical interventions. In the past he has been on azathioprine, sulfasalazine, hydroxychloroquine, and methotrexate. None has been effective recently. He has been taking prednisone (varies from 5 mg to 20 mg a day) for many years. Four months ago, etanercept was begun, and his arthritic pain resolved almost completely. However, over the past 7-8 months he has developed a progressively worsening cough. It has been productive on occasion, but he denies any blood or blood-tinged sputum. Over the last 2 months, he has had increasing shortness of breath with exertion, to the point that he now cannot walk a block without being short of breath.

PAST MEDICAL HISTORY: Diabetes mellitus, adult onset at age 40; probably associated with steroids
Positive PPD 30 years ago and he took INH for 1 year
SOCIAL HISTORY: Worked as a locksmith for 20 years before having to retire for disability
Stopped smoking cigarettes 30 years ago; previously smoked 1 pack/day for 10 years
Doesn't drink alcohol
FAMILY HISTORY: Doesn't know; he was adopted
REVIEW OF SYSTEMS: No fever
No chills
No sweats
No chest pain
No weight loss
No change in vision
No appetite changes
PHYSICAL EXAMINATION:
BP 130/82, P 69, RR 17, T 99° F, appears comfortable at rest
HEENT: PERRLA, EOMI, developing cataract in left eye
TMs clear
Throat clear
Neck: Supple, no masses
Heart: RRR without murmurs, rubs, or gallops
Lungs: Diffuse crackles at left base; no wheezes
Abdomen: Bowel sounds present; no hepatosplenomegaly; no masses
Extremities: Chronic, symmetric, deforming polyarthritis with moderate synovitis of metacarpophalangeal joints
Joints were cool and without effusions
Skin was without evidence of vasculitis or nodules
LABORATORY:
Sputum: Negative for acid-fast bacilli x 3
Liver functions: AST 30 U/L; ALT 28 U/L; total bilirubin 0.2 mg/dL; alkaline phosphatase 200 U/L; GGT 20 U/L; albumin 3.5 mg/dL
Renal function:
BUN 10 mg/dL; creatinine 0.5 mg/dL
Urinalysis: Normal for age
Pulmonary function testing:
Predicted Actual % Predicted
FVC (L) 3.8 1.9 50
FEV1 (L) 2.6 1.5 58
FEV1/FVC (%) 70 80 114
DLCO mL/min/mmHg 26.02 8.63 33
Which of the following do the pulmonary function findings indicate?
a) Severe obstructive lung disease, with no restrictive defect and marked decrease in diffusing capacity
b) Severe obstructive disease with mild restrictive defect and normal diffusing capacity
c) Restrictive ventilatory defect and normal diffusing capacity
d) Restrictive ventilatory defect and marked decrease in diffusing capacity
e) Restrictive ventilatory defect only
Topic

Pulmonary Medicine

Answer

B. Cardiac Output L/min: High; Systemic Vascular Resistance dynes-sec/cm5: Low; Wedge Pressure mmHg: Low

Explanation

Utilizing a Swan-Ganz catheter to generate a hemodynamic profile of shock, such as in this case, is a reasonable question for the exam. They may even throw in more data such as pulmonary artery pressure, mixed venous oxygen saturation, and even left ventricular stroke volume to foul you up. Stick to the parameters above and you should be able to narrow down the answer sufficiently.

Remember: The hallmark of early, "warm" sepsis is a hyperdynamic heart (increased cardiac output) coupled with a very low systemic vascular resistance. Typically the patient in early septic shock is volume depleted and "third spacing" a considerable amount of the fluids given for resuscitation due to the low systemic vascular resistance. In all the other options listed, the systemic vascular resistance is high because it is the only thing holding the blood pressure together!

Volume depletion due to hypovolemic shock (whether hemorrhagic or intravascular) is characterized by a low wedge pressure, a reduced cardiac output, and a high SVR. Cardiogenic shock is defined by a low cardiac output, high-filling pressures (think CHF), and a high SVR. Obstructive shock is typified by a massive PE or a tension pneumothorax. There is reduced cardiac filling, reduced cardiac output, and a high SVR. In pericardial tamponade, the filling pressures will be normal as a reduced volume is acted on by a decreased compliance of the ventricular wall.
Topic

Pulmonary Medicine

Answer

E. None needed unless clinical symptoms/problems develop

Explanation

He is a healthy person without evidence of liver disorder. If he had evidence during the initial evaluation to suggest a liver disorder, then you would draw baseline serum alanine aminotransferase (ALT) and bilirubin. Baseline testing is also indicated for patients with HIV infection treated with HAART, pregnant women, women in the immediate postpartum period (within 3 months of delivery), persons with a history of chronic liver disease (hepatitis B or C, alcoholic hepatitis, or cirrhosis), persons who use alcohol regularly, and persons at risk for chronic liver disease. Baseline testing is no longer absolutely indicated in older persons (> 35 years old), although some experts recommend that baseline and scheduled ALT testing be done in those older than 35 years. For patients with chronic conditions on medications that could cause problems, testing may be warranted. After baseline testing, individuals may be followed every 2-4 weeks depending on the severity of their clinical condition or if baseline laboratory is abnormal.

All patients regardless of age or health status require clinical monitoring! This includes educating patients about signs and symptoms that might indicate a problem with the medication. These include any of the following: unexplained anorexia, nausea, vomiting, dark urine, icterus, rash, persistent paresthesias of the hand and feet, persistent fatigue, weakness or fever lasting 3 or more days, abdominal tenderness (especially right upper quadrant discomfort), easy bruising or bleeding, and arthralgia. Clinical monitoring begins at the first visit and should be done monthly.
A 42-year-old female complains of exertional dyspnea for about 2 years that seems to be gradually progressing. She now has difficulty doing simple household chores without dyspnea. She has no associated cough, sputum, fever, chills, or wheezing. She has occasional episodes of feeling lightheaded with exercise but no palpitations. She has no significant past medical history and takes no medications except for a multivitamin. She is a lifelong nonsmoker. Physical exam reveals normal vitals except a resting oxygen saturation of 89%. Lungs are without abnormal sounds. Cardiovascular exam reveals a 2/6 holosystolic murmur at the left midsternal border, an RV impulse at the left sternal border, and A2 and P2 sounds that are equal in intensity. Pulmonary function tests only reveal a reduced DLCO, which is 45% predicted. Chest radiograph is normal. Echocardiogram reveals normal left ventricular function but is notable for right atrial and ventricular dilatation, 3+ tricuspid regurgitation, and an estimated pulmonary artery systolic pressure of 84 mmHg. Right heart catheterization is performed, which estimated the mean pulmonary artery pressure to be elevated at 55 mmHg. Pulmonary capillary wedge pressure is normal. Chest angiogram is without pulmonary embolus. Serologic testing for connective tissue disease is all negative.

Which of the following is not currently used for treatment in patients with this clinical entity?
a) Subcutaneous prostacyclin therapy
b) Oral cyclophosphamide daily
c) Oral endothelin receptor antagonist
d) Oxygen therapy
e) Warfarin
Topic

Pulmonary Medicine

Answer

E. Exercise challenge test

Explanation

With a normal cardiovascular and pulmonary exam, the most likely cause of the episodic dyspnea in this patient under 40 years of age is exercise-induced bronchospasm (EIB). Because this bronchospasm is episodic and a reversible airways obstruction, spirometry performed while the patient is asymptomatic may well be normal. An exercise challenge test is the most direct way to establish a diagnosis of EIB. This usually involves 6 to 8 minutes of ergometer or treadmill exercise, sufficient to raise the heart rate to 85% of the predicted maximum. A test is generally considered positive if the FEV1 falls by 10% or more, although a fall of 15% is more diagnostic.

Alternatively, surrogate tests to assess bronchial hyperresponsiveness (e.g., cold air hyperventilation, methacholine or histamine inhalation challenge) may be performed in specialized laboratories but do not always correlate with the presence of EIB. If the patient had rales on the exam and was older, the possibility of an interstitial lung disease would have to be entertained, and an HRCT of the chest would be indicated. Remember: 10% of patients with interstitial lung disease will have a normal chest x-ray at the time of presentation. If the patient gave a history of chest pain or syncope with exertion and physical exam revealed a right parasternal heave and an accentuated P2, then the diagnosis of pulmonary hypertension by echocardiography would be warranted. If an upper airway obstruction was suggested by the history or the patient was found to have stridor, a flow-volume loop would be a good screening test for upper airway obstruction. A normal ABG with a normal A-a gradient would make a diffusing capacity limitation unlikely.
An 18-year-old man presents for evaluation and relates that he has a herd of cattle. About 3 weeks ago, he was helping a cow deliver, and he had to assist the cow by manually removing the calf and the placenta. The cow was not ill before the delivery. He reports that he became ill about 2 days ago with a high fever, night sweats, and cough. He has noted that he also has a left upper quadrant tenderness in his belly.

PAST MEDICAL HISTORY: Negative; healthy farm boy
SOCIAL HISTORY: Lives with his mother, a widow
Has 3 cats, 2 dogs, and a pet iguana
Chews tobacco
Doesn't drink alcohol
FAMILY HISTORY: Dad died at the age of 35 in a bull-riding accident
Mother healthy, 40
Has 2 younger sisters
REVIEW OF SYSTEMS: Complains of joint aches and pains with the fever
Headache
Weakness
PHYSICAL EXAMINATION:
BP 110/80, P 110, RR 20, Temp 103° F, Ht 6' 1", Wt 210 lbs
Well-developed, very muscular man in some distress
HEENT: PERRLA, EOMI
TMs clear
Throat: mild erythema
Neck: Supple, no meningismus
Heart: RRR without murmurs, rubs, or gallops
Lungs: Coarse breath sounds with defined crackles at the right base
Abdomen: Bowel sounds present; liver edge palpated 5 cm below right costal margin; spleen tip palpated 4 cm below left costal margin
Extremities: No cyanosis, clubbing, or edema
Skin: No rashes
LABORATORY: WBC: 18,000 with 75% polys, 20% bands
Hgb: 16.0 mg/dL
Platelets: 150,000
Electrolytes: Normal
AST: 100
ALT: 120
CXR: Right lower lobe pneumonia
Which of the following is the likely etiology of his pneumonia?
a) Coxiella burnetii
b) Streptococcus pneumoniae
c) Yersinia pestis
d) Staphylococcus aureus
e) Francisella tularensis
Your next patient is an 18-year-old woman who is HIV-infected. Her most recent CD4 count was 10. She is moving to your area from Iowa. She says she had a TB skin test 2 years ago and some other skin tests, all of which were read as 0 mm. She remembers that the doctor there told her to tell people the number was "0 millimeters" and not "negative."

PAST MEDICAL HISTORY: She has not required hospitalization in 3 years; at that time, she was hospitalized for Pneumocystis pneumonia, which was when she was diagnosed with HIV and found to have AIDS.
MEDICATIONS: Trizivir one PO bid, which she has been on for 3 months (she is now adherent, though she says in the past she had not been)
Bactrim DS one PO M, W, F
Azithromycin q week
SOCIAL HISTORY: Lives with her boyfriend, a welder
She works as a waitress at the local IHOP
Smokes 3 packs/day cigarettes
Doesn't drink
FAMILY HISTORY: Unknown; ran away from home at age 13
REVIEW OF SYSTEMS: Occasional night sweats
Low-grade fevers every 3-5 days
Sore throat on occasion
Cough daily; especially in the morning
Loose stools daily; normal for her is 4-5 bowel movements daily; no blood
Vomiting on occasion
No rash
Decreased appetite
PHYSICAL EXAMINATION: Fairly well-appearing woman in no distress
BP 110/70, P 90, RR 14, Temp 99° F, Ht 5' 5", Wt 110
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple; no masses
Heart: RRR with no murmurs, rubs, or gallops
Lungs: Scattered rhonchi at bases; cleared with cough
Abdomen: Bowel sounds present; liver span 10 cm; no spleen palpated
Extremities: No cyanosis, clubbing, or edema
Skin: Facial acne; no other rashes
LABORATORY:
WBC: 2,400 with 70% lymphs, 20% neutrophils
Hgb:
12.5 mg/dL; MCV 105
Platelets: 450,000
Electrolytes: Normal
Albumin:
3.4 mg/dL
AST: 30 U/L
ALT: 25 U/L
Total bilirubin: 0.4 mg/dL
Viral load: < 50 copies/mL
CD4: 50
She is due for her tuberculosis screening; which of the following do you recommend?
a) PPD containing 5 TU of tuberculin with 2 controls (mumps and Candida)
b) PPD containing 250 TU of tuberculin without controls
2-step boosted PPD with 5 TU of tuberculin (place one today and repeat in 2 weeks)
c) PPD containing 5 TU of tuberculin without controls
d) PPD containing 250 TU of tuberculin with 2 controls (mumps and Candida)
A 50-year-old African-American woman with a history of hypertension and obesity presents with a 4-month history of worsening shortness of breath. She had been able to walk up a flight of stairs without any difficulty about 3 months ago. Now she complains of shortness of breath while walking around her home. Also, at night she has a new onset of orthopnea. She denies other symptoms at this point.

PAST MEDICAL HISTORY: Hypertension for 10 years, treated with HCTZ 25 mg daily
Delivered 5 healthy children in her 20s; no problems during pregnancies
SOCIAL HISTORY: Works in a day care with 30 preschool children
Says her job is very stressful but less stressful than her previous job, which was as a housemother for a fraternity house
Never smoked
Never drank alcohol
No pets
Widowed; lives alone
FAMILY HISTORY: Father, 80; recent MI 1 year ago
Mother, 79; recent admission to nursing home for Alzheimer's
Sister, 55; healthy but obese
Brother, 53; hypertension, on medication
Sister, 48; with SLE
REVIEW OF SYSTEMS: No headaches
No chest pain
No cough
No fever
No sweats
No rashes
No joint complaints
PHYSICAL EXAMINATION: BP 120/85, P 90, RR 16, Temp 98.8° F
Ht 5'2", Wt 260 lbs
HEENT: PERRLA, EOMI, discs sharp
Throat clear
Neck: Supple, no masses
Heart: RRR without murmurs, rubs, or gallops; loud pulmonic second sound
Lungs: Clear to auscultation
Extremities: Bilateral 2+ pitting edema; no cyanosis or clubbing noted
Skin: No rashes
Rectal: Heme-negative
LABORATORY: Pulse oximetry on room air was 93% at rest; with walking dropped to 87%
CXR:



Echocardiogram: Ejection fraction of 80% and pulmonary hypertension with a PA systolic pressure of 61 mmHg. Right ventricular size and function were normal.

Pulmonary function tests: FEV1 of 0.9 L (43% predicted) and an FVC of 1.6 L (59% predicted). High-resolution CT scan showed diffuse pulmonary nodules and hilar enlargement.

Three sputum samples for acid-fast bacilli were negative. She underwent bronchoscopy with transbronchial biopsy for evaluation of her pulmonary nodules. The bronchoscope showed hyperemia with nodular irregularities and distal concentric narrowing in the main, segmental, and proximal subsegmental bronchi.

The transbronchial biopsy is shown in the image below. Special stains for fungi and acid-fast bacilli were negative.



Which of the following is the most likely diagnosis?
a) Bacterial pneumonia
b) Pulmonary sarcoidosis
c) Asbestosis
d) Tuberculosis
e) Granulomatosis with polyangiitis (Wegener's)
Topic

Pulmonary Medicine

Answer

A. TMP/SMX and prednisone

Explanation

Based on the clinical presentation and findings on chest radiograph, this patient has P. jiroveci (formerly known as P. carinii ) pneumonia (PJP). Clinically, patients with HIV and PJP have a gradual onset of symptoms characterized by fever, cough, and progressive dyspnea. Other symptoms may include fatigue, chills, chest pain, and weight loss. Patients with PJP also tend to have diffusion abnormalities and hypoxemia, resulting in lower arterial oxygen saturations. The most common radiographic findings are diffuse bilateral alveolar or interstitial infiltrates. Occasionally findings will include pneumothorax, lobar or segmental infiltrates, cysts, nodules, or pleural effusions. PJP is an opportunistic infection in patients with AIDS when CD+ cell counts drop below 200 cells/µL. Additionally, LDH levels often are elevated but are nonspecific. TMP/SMX remains the initial drug of choice for treatment of PJP. Consensus guidelines recommend that HIV-infected patients with hypoxia be treated with adjunctive corticosteroids.

Although the patient has signs suggestive of oral thrush, this is likely related to Candida , and amphotericin would not be indicated to treat this. Furthermore, fungal infections tend to be more nodular or cavitary in nature than the current patient. Although HIV-infected patients are at risk for Mycobacterium tuberculosis , for which four drug therapies would be indicated, this patient does not present with symptoms consistent with tuberculosis both radiographically and clinically.

On the Board exam they will frequently give you scenarios in which a patient will present with shortness of breath and you have to discern the etiology. Some of their favorites include high-risk procedures/conditions for pulmonary embolism.
A 74-year-old woman with a 100-pack-year history of smoking (2 ppd for 50 years) is essentially dragged in by her husband, who says that she has withered away to nothing and has been acting very confused lately. She says she is fine but keeps calling you her grandchild. You don't get much more information out of her.

PAST MEDICAL HISTORY: Hysterectomy 24 years ago
HTN for 20 years; on an ACE inhibitor
SOCIAL HISTORY: Retired used car salesperson
Lives with her husband of 50 years
Doesn't drink
FAMILY HISTORY: Father died at age 75 of lung cancer
Mother died at age 74 of lung cancer
Brother died at age 74 of lung cancer
Sister died at age 74 of lung cancer
Brother recently diagnosed with lung cancer
REVIEW OF SYSTEMS: No fever or chills
Has had night sweats on occasion
30-lb weight loss in last 6 months
No appetite
Coughed up blood once last week (about a teaspoon, according to husband)
PHYSICAL EXAMINATION:
Oriented only to person, place; thinks the year is 1965
BP 110/70, P 92, RR 14, Temp 99° F, Ht 5' 2", Wt 140
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple, no masses
Heart: RRR with II/VI systolic murmur (heard for 10 years now)
Lungs: Coarse scattered crackles; no focal finding
Abdomen: Bowel sounds present; no hepatosplenomegaly
Extremities:
No cyanosis, clubbing, or edema
LABORATORY: CXR: Central mass seen in right hilum; no cavitation noted
Serum sodium: 120 mg/dL
Urine sodium: 60 mg/dL (normal should be less than 10 mg/dL with this serum sodium)
Based on your findings, which of the following types of lung cancer does this woman most likely have?
a) Adenocarcinoma
b) Small cell carcinoma
c) Large cell carcinoma
d) Bronchoalveolar carcinoma
e) Squamous cell carcinoma
A 38-year-old man presents with an acute asthma attack. He has been feeling bad for a few days. This morning he awakened and could not breathe. When you see him in the emergency department, he is anxious and cannot talk because of his discomfort. You realize that you have to act quickly and note in his chart that he has had to be ventilated 3 times in the past for severe asthma exacerbations.

PAST MEDICAL HISTORY:
As above
Most recent hospitalization was 1 year ago at another hospital
Has been on an inhaled medium-dose steroid, an inhaled long-acting beta2-agonist, and zafirlukast
SOCIAL HISTORY:
Works as a puppet maker
Lives with his friend
FAMILY HISTORY: Mother with severe asthma
Father with coronary artery disease
REVIEW OF SYSTEMS: Deferred for the moment—he is about to crash!
PHYSICAL EXAMINATION: BP 150/95, RR 40 with shallow breaths and marked accessory muscle use, P 120
HEENT: Cyanotic around his lips
Heart: RRR without murmurs, rubs, or gallops
Lungs: Faint squeaks is all you hear
Abdomen: Benign
LABORATORY: ABG: pH 7.06
pCO2 90
PaO2 55
Oxygen saturation 84%
On 100% FiO2
You realize that you are not going to be able to ventilate him effectively without putting him on mechanical ventilation.

Which of the following ventilator settings are appropriate for a severely ill asthmatic patient?
a) Low rate, high tidal volume, high flows
b) Low rate, small tidal volume, high flows
c) Low rate, high tidal volume, low flows
d) High rate, small tidal volume, high flows
e) High rate, high tidal volume, low flows
Topic

Pulmonary Medicine

Answer

E. Silicosis

Explanation

Silicosis is an occupational lung disease characterized by restrictive lung function. Occupational exposures include any exposure to silica dust, which can occur in mining, stone cutting, quarrying, road and building construction, glass manufacturing, and sand blasting. Typically, patients will have biapical distribution of parenchymal lung disease but often will have areas of "eggshell calcification" of hilar lymph nodes. Silicosis is associated with a higher risk of contracting tuberculosis and developing lung cancer as well as strong association with scleroderma and rheumatoid arthritis. Coal worker's pneumoconiosis will have similar radiographic and PFTS findings to silicosis. Eggshell calcification is not associated with this, and there is no increased risk of TB or cancer. Berylliosis is seen in patients with exposure to electronics, nuclear material, or ceramics. Radiographically, it presents with bilateral hilar lymphadenopathy, similar to the appearance of sarcoidosis. Asbestos exposure does carry an increased risk of developing lung cancer, but this association is not seen for tuberculosis. Byssinosis is related to exposure to impurities in cotton, flax, and hemp dusts. It often develops after >10 years of exposure and is associated with a temporal relationship to exposures. For example, patients may complain of difficulty of breathing on the first day of the workweek. It is associated with a gram-negative exotoxin but not tuberculosis.
A 50-year-old man with a history of pneumonia diagnosed 2 days ago presents for follow-up. He was seen as an outpatient and sent home on oral levofloxacin. He says he took 1 pill and it made his stomach hurt, so he stopped the medication. He said he meant to call and let you know, but he was too busy and thought he would get better without the medicine. Now he complains of right-sided chest pain that is pleuritic in character. He says it really hurts to take a deep breath.

PAST MEDICAL HISTORY: Essentially negative; few office visits for sildenafil prescriptions
SOCIAL HISTORY: Works as an attorney; prosecutes medical malpractice cases
Lives alone
FAMILY HISTORY: Mother alive and healthy
Father died at age 70 of myocardial infarction
Brother 49, healthy, mechanic
REVIEW OF SYSTEMS: Fever has been persistent and unremitting since early this morning
Chills prominent
Sputum production has increased markedly since yesterday
Chest pain as described above
Minor sore throat
Generalized body aches and pains
No arthritis
No vision changes
No rash
PHYSICAL EXAMINATION: BP 120/70, P 90, RR 20 (splinting), Temp 103.5° F
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple; no masses
Heart: RRR without murmurs, rubs, or gallops
Lungs: Upper lung fields clear
Left lower lung has scattered crackles
Right lower lung has the following localized findings: absent breath sounds, dullness to percussion, vocal fremitus is absent
Abdomen: Bowel sounds are present; no hepatosplenomegaly
Extremities:
No cyanosis, clubbing, or edema
Skin:
No rashes noted now
LABORATORY: WBC: 15,000 cells/mm3 with 80% polys and 10% bands
Hemoglobin/Hematocrit: 15.5 mg/dL; 52%
Platelets: 350,000
CXR: Marked consolidation of the right LL with pleural effusion noted bilaterally; right much greater than left
Pleural fluid: WBC 70,000 with 90% polys
pH 7.02
Gram stain: Few lancet-shaped gram-positive diplococci
Based on your findings, which of the following is the most appropriate next step?
a) Admit to the hospital, place a chest tube, and start intravenous ceftriaxone and azithromycin.
b) Admit to the hospital, start intravenous ceftriaxone plus azithromycin, and observe on therapy 24 hours before placing a chest tube.
c) Give IM shot of ceftriaxone and oral azithromycin; observe in waiting room and discharge home if doing better in 4 hours.
d) Admit to the hospital, start intravenous ceftriaxone plus azithromycin; get pulmonary consult to decide if he needs a chest tube.
e) Admit to the hospital, place a chest tube, and start intravenous vancomycin and gentamicin (for synergy).
A 70-year-old man with a history of working in a brickyard for 50 years presents for evaluation at his granddaughter's request. He has been retired for 10 years. He is still active and plays bingo at the local church every day. He usually wins about once a week. Members of his bingo group are around his age, and recently one of his contemporaries at the bingo hall was diagnosed with tuberculosis. Your patient has been healthy and has no complaints. He denies weight loss, cough, fevers, or night sweats.

PAST MEDICAL HISTORY: Prostatic hypertrophy diagnosed 5 years ago; doing well currently
HTN for 40 years
MEDICATIONS: Propranolol 20 mg q day
ECASA q day
SOCIAL HISTORY: Widowed for 20 years
Lives alone; still drives without difficulty
Volunteers at local nursing home on occasion
Never smoked; Doesn't drink alcohol
FAMILY HISTORY: Mother died at age 80 of "old age"
Father died at age 75 of stroke
Brother alive, 68, healthy except HTN
Sister died at age 50 of stroke
REVIEW OF SYSTEMS: No sore throat
No vision changes
No chest pains
No headaches
Minor arthritis-type pain in knees in the early morning; better with movement
GU symptoms much improved; no difficulty initiating urine stream
PHYSICAL EXAMINATION: BP 130/69, P 66, RR 15, Temp 98.8° F
Ht 6' 1", 190 lbs
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple, no masses
Heart: RRR without murmurs, rubs, or gallops
Lungs: Coarse breath sounds but clear
Abdomen: Bowel sounds present in all 4 quadrants, no hepatosplenomegaly, nontender
Extremities: No cyanosis, clubbing, or edema
GU:
Normal male genitalia, no masses
LABORATORY: CXR: Small nodules located in upper lobes; calcified hilar lymph nodes with "hilar eggshell calcification"
PPD: 20 mm at 72 hours
3 induced sputum samples for AFB: All negative smears and cultures
Based on these findings, which of the following is the most appropriate next step?
a) Start INH prophylaxis.
b) Initiate workup for asbestos-related disease process.
c) Ignore +PPD in this 70-year-old man. Sputum tests are negative; therefore, it is unlikely he needs prophylaxis.
d) Initiate 4-drug therapy for tuberculosis.
e) Start treatment for silicosis.
Topic

Pulmonary Medicine

Answer

E. Start isoniazid, rifampin, pyrazinamide, and ethambutol.

Explanation

This question tests your knowledge of pleural tuberculosis. The case includes a health care worker with a TB skin test of 12 mm, which is positive (10 mm is the cut-off for a negative test in health care workers). Therefore, at minimum, this man has latent tuberculosis. Next, you must consider how the pleural effusion relates to his positive TB skin test. You are asked to recall that tuberculosis can variably present, and one manifestation is isolated disease of the pleural space. The pleural fluid has a slightly low glucose, lymphocyte predominance, and a pleural fluid LDH value of > 2/3 the normal value of serum (qualifying the fluid as an exudate); hence, the pleural fluid is highly suggestive of tuberculosis. The fact that the acid-fast smears do not show organisms does not exclude tuberculosis and is a rather common occurrence.

This patient with a positive TB skin test and a pleural effusion consistent with tuberculosis should be evaluated next according to his risk for true tuberculosis. If he is truly at high risk for TB, he should be treated while undergoing further testing and awaiting cultures. If he is determined to be low risk, he can be observed. This patient would be high risk because he is a health care worker. Therefore, the correct answer is to start 4-drug therapy against tuberculosis. Further workup should include a repeat thoracentesis with multiple samples submitted for AFB smears and cultures and a pleural fluid ADA level. If the ADA level cannot be performed, a pleural biopsy is needed to send tissue for pathology and mycobacterial culture.

Ceftriaxone is ineffective against tuberculosis. Prednisone is used in tuberculosis only in cases of CNS disease and TB pericarditis.
Topic

Pulmonary Medicine

Answer

B. Initiation of drotrecogin alfa (activated) by continuous IV infusion for 96 hours

Explanation

This is an example of a patient with septic shock with evidence of hypotension and organ hypoperfusion with an elevated lactate level. Early initiation of treatment is important with clear evidence of benefit for certain interventions. The early initiation of targeted empiric antibiotics has been shown to improve mortality. Maintenance of organ perfusion is vital to prevent end organ ischemia and failure. Placement of a central venous catheter can assist with the delivery of intravenous fluids, antibiotics, blood products, and vasopressors if indicated. Furthermore, estimates of intravascular filling pressures can be obtained from properly placed central venous catheters. Early goal-directed therapy in severe sepsis has been a protocol that has shown mortality benefit. This includes initial crystalloid infusion for goal CVP to 8-12 mmHg. If the patient remains hypotensive despite this, then vasopressors should be initiated. Admission to an intensive care unit would be appropriate given the evidence of septic shock. Drotrecogin alfa is a recombinant form of human activated protein C that has antithrombotic, antiinflammatory, and profibrinolytic properties. Initial studies suggested that there was some mortality benefit in patients with very severe sepsis. However, subsequent studies have not shown efficacy in the setting of the sepsis syndrome and the manufacturer has now withdrawn this medication from the market.
A 25-year-old asthmatic patient has a history of frequent exacerbations. On CXR, she frequently has lung infiltrates that migrate and do not seem to respond to antibiotic therapy. She is usually afebrile during these episodes, but it really sets off her asthma and she has a significant exacerbation. Usually, she has to be admitted to the hospital and placed on systemic steroids, with aggressive pulmonary management.

PAST MEDICAL HISTORY: Asthma since early childhood; has never required mechanical ventilation
Has 1 child, age 2; no problems during pregnancy
MEDICATIONS: Albuterol prn
Cromolyn sodium daily
Zafirlukast daily
SOCIAL HISTORY: A 3rd year medical student (considering a career in Radiology)
Married and lives with husband and 2-year-old son
FAMILY HISTORY: Mother 50 and healthy
Father 50 and has hypertension
No siblings
REVIEW OF SYSTEMS: Occasional headache
Stressed by 3rd year rotations
PHYSICAL EXAMINATION:
Well-developed, well-nourished woman in moderate respiratory distress
BP 110/60, P 90, RR 30, Temp 98° F
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple; no masses
Heart: RRR without murmurs, rubs, or gallops
Lungs: Scattered wheezes especially in upper lung fields
Poor airway movement
Few scattered crackles
Abdomen: Bowel sounds present; no hepatosplenomegaly
Extremities: No cyanosis, clubbing, or edema
Skin: No rashes
LABORATORY: WBC: 10,000 with 50% polys, 20% lymphs, 30% eosinophils
Hgb: 13.5 mg/dL
Platelets: 340,000
CXR: Scattered infiltrates throughout all lung fields
Sputum: Normal flora on bacterial stain
KOH is shown in this image: Branching yeasts



Based on your findings, which of the following is the best treatment for her condition?
a) Systemic corticosteroids and itraconazole
b) Amphotericin B 1 mg/kg IV q day
c) Fluconazole 200 mg bid x 1 day then once daily thereafter
d) Itraconazole 200 mg bid x 3 days, then daily thereafter
e) Amphotericin gargles with 5 mg in a 200 cc suspension
Topic

Pulmonary Medicine

Answer

B. Start treatment with a medium dose inhaled corticosteroid along with albuterol as needed.

Explanation

This patient with a history of chronic asthma has symptoms consistent with uncontrolled asthma. Her chronic dry cough, exertional dyspnea, and nocturnal cough are common symptoms found in asthma. Additionally, increased symptoms with certain exposures such as cold air, perfumes, smoke, dusts, pets and pet dander, and other allergens suggest a history of bronchial hyperresponsiveness.

This patient has almost daily symptoms consistent with moderate persistent asthma. Based on NHLBI guidelines for asthma management, first-line treatment for persistent asthma of any severity is an inhaled steroid (ICS). As the severity increases, then the dosage of the ICS may be increased with other therapies added on. For those with moderate severity asthma, long acting beta-agonists may be added to low dose ICS for maintenance. However, long acting beta-agonists (LABAs) should not be used in asthma without the concomitant use of ICSs. In fact, some studies have suggested potential for harm in patients who received LABAs alone.

Allergy testing might be helpful for those patients with uncontrolled asthma despite adequate maintenance therapy. Additionally, patients may report worsening of symptoms with certain exposures in different locations, and allergy testing might help the patient with allergen avoidance. In this patient, however, no history of worsening with exposures nor adequate maintenance therapy was given.

Gastroesophageal reflux disease (GERD) may be a cause for worsening asthma symptoms. However, studies have shown that treatment of asymptomatic GERD does not improve symptoms. This patient did not endorse symptoms of GERD, and, thus, a proton pump inhibitor is unlikely to be helpful.
Topic

Pulmonary Medicine

Answer

E. Idiopathic pulmonary fibrosis

Explanation

Idiopathic pulmonary fibrosis (IPF) is a diagnosis of exclusion with histopathologic findings of usual interstitial pneumonitis (UIP). Heterogenous changes are noted on biopsy ranging in stages from early with inflammation to late with severe fibrosis. Patients generally present in middle age with dry cough and progressive dyspnea. Biopsy will confirm the diagnosis of UIP or exclude other diagnosis. However, in the absence of any evidence to support an alternative diagnosis (serologic tests, drug/toxin/occupational exposure, other history), and then radiographic evidence on chest CT, this may be adequate to make a diagnosis without surgical lung biopsy. Characteristic radiographic findings include bibasilar reticular opacities, minimal ground glass opacities, honeycombing, and traction bronchiectasis. Sarcoidosis can present with areas of fibrosis along with areas of inflammation, but biopsy typically will reveal non-caseating granulomas. Acute respiratory distress syndrome is a rapid onset disorder that leads to respiratory failure. This patient's history is more insidious in onset, so it is inconsistent. Emphysema will not have the chest CT findings or physical exam findings of crackles. A biopsy would reveal emphysematous areas of lungs with destroyed alveolar walls. Asbestosis does cause pulmonary fibrosis with similar radiographic and pathologic findings of IPF. However, there is no history to suggest asbestos exposure, so asbestosis would be unlikely.
Topic

Pulmonary Medicine

Answer

E. Add salmeterol bid.

Explanation

This is a common question on Board exams requiring you to determine whether a patient's asthma is controlled. Because the patient is on long-standing asthma medications, you will assess her level of "control" (remember that "severity" assessments are made at initial presentation in patients not yet prescribed long-term control medications). First determine the treatment "step" the patient is receiving now: low-dose ICS +prn SABA (Step 2 treatment). Next, determine how well the Step 2 treatment is controlling her asthma. From the asthma guidelines, note that daily symptoms indicate "very poorly controlled" disease, and nocturnal symptoms 3x/week indicate "not well-controlled" disease. Therefore, assign her the most severe classification of "very poorly controlled." Next determine how to manage a patient whose asthma is very poorly controlled. The recommendation is to consider a short course of systemic steroids, and step up her treatment regimen 1-2 steps. Increasing this patient's regimen by 1-2 steps would include adding either a LABA and/or increasing her inhaled steroids to medium-dose.

Of the choices listed, adding salmeterol (a LABA) is the only correct answer. Theophylline and montelukast additions to low-dose ICS are only alternatives to the preferred Step 3 treatment, and alternative options should not take precedence over the preferred Step 3 recommendation. 360 mcg of beclomethasone is the highest available dose of this medication and would be considered Step 5 treatment. A LABA should be added prior to increasing an ICS to the highest dose. Ipratropium is not used in the outpatient control of persistent asthma.

Certainly, you should consider whether this patient needs a dose of oral corticosteroids. You could make this assessment by performing a post-bronchodilator FEV 1 measurement. However, prescribing corticosteroids is not a choice in the list of answers.
A 50-year-old male patient is brought to your office at his wife's insistence. You have seen him in the past for borderline hypertension, but when you last saw him 2 years ago, he was on no medications. His wife has insisted that he come today because she says that he is always sleeping. She adds that he fell asleep parking the new car in the driveway and crashed through the garage wall. She states that his snoring has gotten so bad that she has moved to another bedroom. The patient admits to being even sleepier during the daytime, though he thinks that he gets a good night's sleep. He knows he snores, but it doesn't bother him. He admits to waking up tired and often with morning headaches. He is concerned about his performance at work, where he sometimes operates heavy equipment. He denies that he is depressed and states that he doesn't use drugs or alcohol.

On physical exam, you note that he has gained 20 lbs since his visit 2 years ago and that he now weighs 230 lbs. He is 5' 8". Blood pressure on repeated measurement is 170/105. On examination of his throat, you notice for the first time his large uvula. Cardiopulmonary as well as neurological exams are within normal limits.

Which of the following would you recommend?
a) Recommend an initial trial of acetazolamide and theophylline before more invasive testing is performed.
b) Order polysomnography with trial of nasal continuous positive airway pressure (CPAP).
c) Ear, nose, and throat consultation for uvulopalatopharyngoplasty.
d) Order polysomnography.
e) Advise weight loss, exercise regimen, and follow-up visit in 1 month.
Topic

Pulmonary Medicine

Answer

E. Lymphangioleiomyomatosis (LAM)

Explanation

This woman has sporadic lymphangioleiomyomatosis (LAM), a rare cystic lung disease caused by abnormal proliferation of smooth muscle cells that affects premenopausal women (average age 35) almost exclusively. Progressive exertional dyspnea with worsening airflow limitation, recurrent pneumothoraces, and chylous pleural effusions are the common clinical manifestations. 30-50% of women with sporadic LAM also have renal angiomyolipomas that are usually clinically silent.

Tuberous sclerosis complex-associated LAM, another form of the condition, includes tumors in the brain, skin, and other organs, causing seizures and intellectual delay. The diagnosis of LAM can be made by high-resolution CT without biopsy in classic cases; lung biopsy (positive for the HMB-45 immunohistochemistry assay) may be required in others. LAM's major mimics on HRCT are pulmonary Langerhans cell histiocytoma and emphysema.

In a trial, enrolling 89 women, those randomized to sirolimus had stable or improved lung function (FEV 1 and DLCO) and improved respiratory symptoms over 12 months of treatment, compared to those taking placebo. After stopping the drug, though, decline in lung function resumed. In an observational series, 12 women with chylous effusions due to LAM, who were treated with sirolimus, had marked improvement or resolution of their effusions.

Lung transplantation is an important treatment option for severe cases of LAM. Early referral to a transplant center for those with severe disease seems prudent.

Alpha-1-antitrypsin deficiency is a genetic disorder and not acquired—so it is ruled out by a previously normal Alpha-1-antitrypsin level.

Idiopathic pulmonary fibrosis has a honeycombing and denser fibrotic changes on CT.
A 75-year-old Caucasian male with recent fracture of his right femur 3 hours ago presents by ambulance and is seen by an orthopedist, who places him in a cast and admits him for observation. Three hours later, you are called by the doctor because his patient is now short of breath and confused. He thinks the patient might have pneumonia because he is breathing fast. He is consulting you for antibiotic choices. You tell him you will take over the care for the respiratory disorder.

On evaluation, you find a disheveled elderly man lying in the bed in traction. He is having some difficulty breathing. He has supplemental oxygen with a 40% FiO2 facemask that is keeping his pulse oximetry at 95%. He is unable to answer any questions due to his dyspnea, and he is also quite confused. Eventually, he says the year is 1960 and that you are his 5th grade school teacher.

PHYSICAL EXAMINATION: BP 130/70, P 99,Temp 99° F, RR 24
HEENT: PERRLA, EOMI; conjunctival petechiae
TMs clear
Throat clear
Neck: Supple, no masses; petechiae on neck
Heart: RRR without murmurs, rubs, or gallops
Lungs: Coarse breath sounds; few basilar scattered crackles
Abdomen: Bowel sounds present; no hepatosplenomegaly
Extremities: No cyanosis, clubbing, some edema on the fractured leg at the ankle; exam of fractured extremity limited but neuro-vasculature looks to be grossly intact
LABORATORY: Pending
Based on the history and physical findings, which of the following is the most likely diagnosis?
a) Cerebrovascular accident
b) Fat embolism
c) Drug toxicity
d) Hospital psychosis
e) Aspiration pneumonia
Topic

Pulmonary Medicine

Answer

A. CTA

Explanation

If you did this question sequentially, you can see that I changed this question slightly from the first time you saw it (if you didn't do this sequentially, then never mind and forget that I said this ☺). I made the patient a little older and gave him a smoking history as a risk factor for occult malignancy. These two changes make his risk for DVT and PE much higher than in the first setting, where the patient was young and healthy. Immediately, your differential diagnosis should include PE at the top of the list because of these changes in epidemiology.

On first inspection of the blood gas, you can appreciate the respiratory alkalosis. This is more supportive evidence of a PE, but you could consider that he's hyperventilating because of a panic attack. If you calculate the A-a gradient, you'll see that even though a PO 2 of 85 doesn't look so bad, the gradient is abnormal:

P A O 2 = 150 - (PCO 2 x 1.25) = 150 - (32 x 1.25) = 110

A-a gradient = 110 - 85 = 25 (normal 5-20), elevated!

Something's going on at the alveolar-capillary unit.

Of the choices listed, the only appropriate next step to evaluate for a pulmonary embolism is to perform a CTA, which is now considered first-line imaging in patients in whom you suspect PE. He does not have anaphylaxis, so epinephrine is inappropriate. He does not have asthma or COPD, so inhalation medications are a waste of time. Changing his antidepressant might be appropriate if this were a true panic attack, but the abnormal A-a gradient mandates a workup for pulmonary embolism.
Topic

Pulmonary Medicine

Answer

D. Patients may have pulmonary function tests that are normal.

Explanation

Based on NHLBI guidelines for the management of asthma, all patients with asthma that is categorized as persistent should be considered for maintenance therapy. First line medications are inhaled corticosteroids with the dose recommendations based on the degree of severity. Short-acting beta-agonists may be helpful for exercise-induced asthma and may be used as rescue inhalers in periods of acute shortness of breath. Long-acting beta-agonists (LABAs), such as salmeterol or formoterol, should not be used for these purposes. In fact, LABAs have been shown in some studies to be associated with a higher risk of death, particularly if not used in conjunction with inhaled steroids. Furthermore, treatment with LABAs without concomitant use of inhaled steroids is not advised. Although treatment of symptomatic GERD may help control asthma symptoms, multiple studies have shown that treatment of asymptomatic GERD did not alter the course of asthma in terms of symptoms, exacerbations, or dyspnea scores. Asthma is characterized as episodic airflow obstruction that is fully or partially reversible. Therefore, patients may not manifest any objective signs of obstruction when pulmonary function testing is performed, but this doesn't exclude the diagnosis of asthma. Methacholine challenge testing evaluates the tendency of airways to cause bronchoconstriction in response to antigens such as methacholine. The patient inhales escalating doses of methacholine, and the dose that causes a 20% reduction in FEV1 is graphed. If there is not a reduction of the FEV1 by at least 20%, then the test is negative, which essentially rules out asthma.
An 18-year-old college freshman developed a sore throat approximately 8 days ago that was cultured and did not grow Streptococcus pyogenes. However, her throat culture did grow Staphylococcus aureus. She presents today with complaint of fever and cough that began last night. She also describes hoarseness since she has had her sore throat symptoms. The sore throat symptoms resolved after 3 days without specific antimicrobial therapy.

PAST MEDICAL HISTORY: Attention deficit disorder diagnosed at age 8; on no medication since 4 years ago
SOCIAL HISTORY: Recently moved here for college
Doesn't smoke or drink alcohol
Not sexually active
Has a pet parrot back home
FAMILY HISTORY: Mother 40, healthy
Father 42, in prison for securities fraud
Sister 15, pregnant
REVIEW OF SYSTEMS: Negative for other symptoms; no rash, no joint manifestations
PHYSICAL EXAMINATION: BP 110/70, P 88, Temp 100° F, RR 18
Ill-appearing woman in no acute distress
HEENT: PERRLA, EOMI, wears contact lenses
TMs clear
Throat: slightly erythematous; no exudates
Neck: Supple, no meningismus
Heart: RRR without murmurs, rubs, or gallops
Lungs: Coarse breath sounds with crackles heard on the left base
Abdomen: Bowel sounds present in all 4 quadrants, nontender; no hepatosplenomegaly
Extremities: No cyanosis, clubbing, or edema
LABORATORY:
CXR: Left lower lobe infiltrate
Besides Streptococcus pneumoniae, which of the following is a likely etiology for her pneumonia?
a) Chlamydia trachomatis
b) Staphylococcus aureus
c) Chlamydophila psittaci
d) Chlamydophila pneumoniae
e) Haemophilus influenzae type b
Topic

Pulmonary Medicine

Answer

C. Maintenance of tidal volumes at 6 mL/kg of ideal body weight

Explanation

This patient has pneumonia, which has progressed to acute respiratory distress syndrome (ARDS). The clinical definition for ARDS includes:

Acute onset of diffuse bilateral infiltrates
PaO2 ratio < 200 (< 300 for acute lung injury [ALI])
No evidence of cardiogenic pulmonary edema
Mechanical ventilatory support is almost always necessary for patients with ARDS. This inflammatory condition has been extensively studied, and outcomes continue to improve. However, the only proven intervention to reduce mortality is a lung protective strategy. Ventilatory support with a goal tidal volume (TV) of 6 mL/kg of ideal body weight and limitation of plateau pressures < 30 cm (protective group) was compared to those with goal TV of 12 mL/kg with no limit to plateau pressures (traditional group). Those in the protective group had a significant reduction in mortality. Associated with a lung-protective strategy was worsening ventilation, but this permissive hypercapnia still resulted in better outcomes.

The use of the right heart catheter in the ICU has diminished significantly. Many studies have shown that use of these catheters and the information they provide does not lead to better outcomes, including conditions such as ARDS. Nitric oxide is a specific pulmonary vasodilator that is delivered by inhalation gas. It has been shown to improve oxygenation temporarily. However, no mortality benefit has ever been shown, and it may, in fact, be associated with worse outcomes. Systemic steroids have not improved mortality but may improve lung injury scores if initiated early in the course of ARDS
Topic

Pulmonary Medicine

Answer

A. Mechanical ventilation with tidal volumes set at 6-8 mL/kg of ideal body weight

Explanation

This patient presents with hypoxemic respiratory failure associated with bilateral alveolar infiltrates, high FiO2 requirement, and no evidence of congestive heart failure. This is most consistent with the acute respiratory distress syndrome (ARDS). The leading differential diagnosis for ARDS is congestive heart failure, but her echocardiogram is not supportive of significant cardiac dysfunction. The most common etiologies for ARDS are sepsis, pneumonia, aspiration, and transfusion-related acute lung injury. ARDS requires support by mechanical ventilation in a great majority of patients.

Studies have shown a reduction in mortality when lung protective strategies are used (6-8 mL/kg) as compared to traditional strategies (10-12 mL/kg). Unfortunately, all other interventions for ARDS have not shown a mortality benefit. The use of neuromuscular blockade may be beneficial in the first 24 hours of ARDS to improve oxygenation.

Prone positioning, which involves placing the patient on their front, has also been shown to improve oxygenation for brief periods of time. Use of high-dose steroids have not been shown to be beneficial in ARDS, although medium-dose steroids may help with lung injury scores if started early in the course of ARDS. Nitric oxide is a selective pulmonary vasodilator that will temporarily improve oxygenation. However, studies have not revealed any benefit and, in fact, may be harmful in patients with ARDS.
A 51-year-old female presents in an outpatient clinic with a new onset of a rash on her back and chest. This rash began about 2-3 months ago. Initially, she thought it was some form of fungal infection or allergic reaction and applied a 1% hydrocortisone cream without much benefit. The rash was not particularly itchy. At the same time, she had begun to develop some pain in her shoulders and hips but no early morning stiffness and no swelling of the joints of her fingers or toes. At age 16, she had presented with unexplained painful nodules on her lower extremities, but the cause of this was never fully understood and she has never had any recurrence. During her second normal pregnancy, she developed a weakness of one side of her face and was told that she had a Bell's palsy. Her facial expression returned to normal fairly soon after the birth of her child. Her internist had been concerned because he had found mild elevations of her calcium levels 3 years ago and again 6 months ago, but these have normalized on their own. There was no particular explanation found for this at that time.

On examination, she was well appearing. Height was 5' 7", weight was 136, BP was 127/76, and pulse was 72. Cardiac and respiratory exams were benign. The abdomen was without hepatosplenomegaly. Musculoskeletal exam revealed no joint synovitis. Neurological exam was normal without any proximal myopathy. Cutaneous exam revealed several circumscribed, somewhat elevated, 2 x 2 coin-sized lesions on her chest and back. Her dermatologist suggested a biopsy.

Which of the following is the most likely pathological finding that could be obtained from the skin biopsy of one of these coin lesions?
a) Panniculitis
b) Non-caseating granulomatous inflammatory changes
c) Interface dermatitis
d) Eosinophilic fasciitis
Topic

Pulmonary Medicine

Answer

B. Use of oxygen at 2 LPM daily with rest and exertion

Explanation

The patient described has obstructive disease based on his PFTs. Based on his FEV 1 , his COPD disease severity would be categorized as severe. Multiple interventions have proven to be beneficial for these patients, with endpoints including improvements in survival, decreased number of exacerbations, reduced hospitalizations, and improved quality of life.

Smoking cessation has been shown to significantly reduce the decline of lung function in a previous smoker. Although lung function will not substantially improve, the rate of decline can approximate that of a nonsmoker after one year of smoking cessation. Pulmonary rehabilitation has been shown to reduce hospitalizations, increase exercise endurance, and improve quality of life. It should be considered in all patients with symptomatic COPD. Inhaled corticosteroids have been shown to reduce the number of exacerbations in those patients with COPD with an FEV 1 < 50% predicted. The influenza vaccine should be considered in all patients with COPD regardless of severity. It has been shown to lead to a 52% reduction in hospitalizations for all episodes of influenza and pneumonia and a 70% reduction in deaths from all causes. Oxygen is the only modality proven to improve the long-term mortality in those patients with COPD who meet certain qualifications. The criteria to start continuous oxygen (ideally 24 hrs but 15 hrs minimum) include:

Resting P a O 2 < 55, O 2 Sat < 88%, P a O 2 < 59 with evidence of cor pulmonale or erythrocytosis.

The patient in this scenario does not meet these criteria based on oximetry testing, and thus the use of oxygen has not been shown to be beneficial in this population.
A 35-year-old woman who had a stillbirth at 25-weeks gestation approximately 2 weeks previously presents with increasing dyspnea for 6 days, which has progressed to the point that she cannot perform daily activities without resting. Walking to the kitchen from her den causes severe dyspnea. She has no history of orthopnea or paroxysmal nocturnal dyspnea, chest pain, cough, or hemoptysis. She has no history of swelling or pain over her calves, and she has not had a history of bleeding disorder or thromboembolism. She has had 3 full-term normal vaginal deliveries 18 years, 6 years, and 3 years previously.

PAST MEDICAL HISTORY: As above; otherwise negative
SOCIAL HISTORY: Vice-President of Marketing for major computer company
Lives with husband and 3 children
Has never smoked
Drank glass of wine/week before was pregnant; none during pregnancy
REVIEW OF SYSTEMS: No fever
No chills
No productive cough
10-lb. weight loss after delivery
PHYSICAL EXAMINATION:
BP 130/90 mmHg, Pulse 125/min, RR 24/min, Temp 99.1° F
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple; no masses
Right jugular venous pressure was not raised
Wave pattern showed prominent Y collapse
Heart: Point of maximal impulse: 5th intercostal space in the midclavicular line with a parasternal heave
S1 was loud; S2 with normal splitting with a loud pulmonary component
S3 was present
Holosystolic murmur over left lower sternal border; increasing with inspiration
Lungs: Scattered rhonchi
Abdomen:
Bowel sounds present; no masses; no hepatosplenomegaly, nontender
Extremities: No cyanosis, clubbing, or edema
LABORATORY: ECG: Right axis deviation, an S-wave in Lead I, and a Q-wave and inverted T-wave in lead III (S1, Q3, T3). T-wave inversion in leads V2 and V3, and S wave persistence in leads V5 and V6.
CXR: Normal
CBC: WBC 7100/mm3; hemoglobin 11.5 gm/dL; platelets 375,000
ESR: 15 mm in 1 hour
Glucose: 90 mg/dL
BUN: 30 mg/dL
Creatinine: 0.8 mg/dL
Echocardiogram: Dilatation of the right ventricle and right atrium; moderate valvular insufficiency noted.

Based on your findings, which of the following is the most likely diagnosis?
a) Myocardial infarction
b) Pulmonary embolism
c) Sepsis
d) Bacterial pneumonia
e) Bacterial endocarditis
You are seeing a 70-year-old man with severe COPD for follow-up. He quit smoking about 5 years ago, but his health has continued to deteriorate. He is at the point now where he cannot ambulate in his home without getting severely short of breath. He wants to know if there is anything else that he can do to improve his health status. You explain to him that supplemental oxygen may be beneficial to him, but you will have to do some laboratory studies to demonstrate to Medicare that they should pay for this. He agrees to the testing.

PAST MEDICAL HISTORY: History of coronary artery disease; status-post 4 vessel CABG 5 years ago
History of gout
History of MI in 1992
Multiple hospitalizations for COPD exacerbations—about once a year on average in the last 10 years
Morbid obesity
SOCIAL HISTORY: Lives with his new wife of 2 years, Bambi, a 28-year-old dancer
Drinks 2 glasses of red wine every night
Quit smoking 5 years ago; before that, he smoked 2 packs/day for 50+ years
FAMILY HISTORY: No change from the last 20 H&Ps you've done; documented well for the chart
REVIEW OF SYSTEMS: Occasional headache
Occasional sore throat
Dyspnea on exertion at 5 feet
Stable exertional chest pain; usually relieved with one nitroglycerin or rest
Cough: productive cough every morning of every day; no change in character or frequency
No nausea or vomiting
Increased difficulty initiating his urine stream
PHYSICAL EXAMINATION:
BP 126/67, HR 86, RR 28, Temp 97.9° F
MS: Oriented x 3
General: Obese man in no distress at rest; but when you saw him walk in from the waiting room he was markedly distressed.
HEENT: Left cataract
Throat clear; dentures
Neck: No masses, no bruits
Heart: RRR without murmurs, rubs, or gallops
Lungs: Chronic crackles throughout; no change from previous examinations; prolonged expiratory phase noted as usual
Abdomen: +BS, soft, nontender
Neuro: CN grossly intact; reflexes equal and symmetrical
Motor: Full strength throughout with normal muscle tone and bulk
Sensory: Unremarkable
LABORATORY: ABG: 7.5 PCO2 = 50; PaO2 = 50; Oxygen saturation 85%
Based on your findings, which of the following should you recommend?
a) Supplemental oxygen is not indicated based on his laboratory values.
b) Supplemental oxygen is not indicated based on his physical examination.
c) Supplemental oxygen should be worn 24 hours a day by this patient.
d) Supplemental oxygen worn intermittently would be better than continuous oxygen therapy because of the concern that his respiratory drive will be too suppressed on continuous oxygen therapy.
e) Supplemental oxygen may be indicated, but you need more information.
Your next patient is an 18-year-old woman who is HIV-infected. Her most recent CD4 count was 10. She is moving to your area from Iowa. She says she had a TB skin test 2 years ago and some other skin tests, all of which were read as 0 mm. She remembers that the doctor there told her to tell people the number was "0 millimeters" and not "negative."

PAST MEDICAL HISTORY: She has not required hospitalization in 3 years; at that time, she was hospitalized for Pneumocystis pneumonia, which was when she was diagnosed with HIV and found to have AIDS.
MEDICATIONS: Trizivir one PO bid, which she has been on for 3 months (she is now adherent, though she says in the past she had not been)
Bactrim DS one PO M, W, F
Azithromycin q week
SOCIAL HISTORY: Lives with her boyfriend, a welder
She works as a waitress at the local IHOP
Smokes 3 packs/day cigarettes
Doesn't drink
FAMILY HISTORY: Unknown; ran away from home at age 13
REVIEW OF SYSTEMS: Occasional night sweats
Low-grade fevers every 3-5 days
Sore throat on occasion
Cough daily; especially in the morning
Loose stools daily; normal for her is 4-5 bowel movements daily; no blood
Vomiting on occasion
No rash
Decreased appetite
PHYSICAL EXAMINATION: Fairly well-appearing woman in no distress
BP 110/70, P 90, RR 14, Temp 99° F, Ht 5' 5", Wt 110
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple; no masses
Heart: RRR with no murmurs, rubs, or gallops
Lungs: Scattered rhonchi at bases; cleared with cough
Abdomen: Bowel sounds present; liver span 10 cm; no spleen palpated
Extremities: No cyanosis, clubbing, or edema
Skin: Facial acne; no other rashes
LABORATORY:
WBC: 2,400 with 70% lymphs, 20% neutrophils
Hgb:
12.5 mg/dL; MCV 105
Platelets: 450,000
Electrolytes: Normal
Albumin:
3.4 mg/dL
AST: 30 U/L
ALT: 25 U/L
Total bilirubin: 0.4 mg/dL
Viral load: < 50 copies/mL
CD4: 50
She is due for her tuberculosis screening; which of the following do you recommend?
a) PPD containing 5 TU of tuberculin with 2 controls (mumps and Candida)
b) PPD containing 250 TU of tuberculin without controls
2-step boosted PPD with 5 TU of tuberculin (place one today and repeat in 2 weeks)
c) PPD containing 5 TU of tuberculin without controls
d) PPD containing 250 TU of tuberculin with 2 controls (mumps and Candida)
A 50-year-old African-American woman with a history of hypertension and obesity presents with a 4-month history of worsening shortness of breath. She had been able to walk up a flight of stairs without any difficulty about 3 months ago. Now she complains of shortness of breath while walking around her home. Also, at night she has a new onset of orthopnea. She denies other symptoms at this point.

PAST MEDICAL HISTORY: Hypertension for 10 years, treated with HCTZ 25 mg daily
Delivered 5 healthy children in her 20s; no problems during pregnancies
SOCIAL HISTORY: Works in a day care with 30 preschool children
Says her job is very stressful but less stressful than her previous job, which was as a housemother for a fraternity house
Never smoked
Never drank alcohol
No pets
Widowed; lives alone
FAMILY HISTORY: Father, 80; recent MI 1 year ago
Mother, 79; recent admission to nursing home for Alzheimer's
Sister, 55; healthy but obese
Brother, 53; hypertension, on medication
Sister, 48; with SLE
REVIEW OF SYSTEMS: No headaches
No chest pain
No cough
No fever
No sweats
No rashes
No joint complaints
PHYSICAL EXAMINATION: BP 120/85, P 90, RR 16, Temp 98.8° F
Ht 5'2", Wt 260 lbs
HEENT: PERRLA, EOMI, discs sharp
Throat clear
Neck: Supple, no masses
Heart: RRR without murmurs, rubs, or gallops; loud pulmonic second sound
Lungs: Clear to auscultation
Extremities: Bilateral 2+ pitting edema; no cyanosis or clubbing noted
Skin: No rashes
Rectal: Heme-negative
LABORATORY: Pulse oximetry on room air was 93% at rest; with walking dropped to 87%
CXR:



Echocardiogram: Ejection fraction of 80% and pulmonary hypertension with a PA systolic pressure of 61 mmHg. Right ventricular size and function were normal.

Pulmonary function tests: FEV1 of 0.9 L (43% predicted) and an FVC of 1.6 L (59% predicted). High-resolution CT scan showed diffuse pulmonary nodules and hilar enlargement.

Three sputum samples for acid-fast bacilli were negative. She underwent bronchoscopy with transbronchial biopsy for evaluation of her pulmonary nodules. The bronchoscope showed hyperemia with nodular irregularities and distal concentric narrowing in the main, segmental, and proximal subsegmental bronchi.

The transbronchial biopsy is shown in the image below. Special stains for fungi and acid-fast bacilli were negative.



Which of the following is the most likely diagnosis?
a) Bacterial pneumonia
b) Pulmonary sarcoidosis
c) Asbestosis
d) Tuberculosis
e) Granulomatosis with polyangiitis (Wegener's)
Your next patient is an 18-year-old woman who is HIV-infected. Her most recent CD4 count was 10. She is moving to your area from Iowa. She says she had a TB skin test 2 years ago and some other skin tests, all of which were read as 0 mm. She remembers that the doctor there told her to tell people the number was "0 millimeters" and not "negative."

PAST MEDICAL HISTORY: She has not required hospitalization in 3 years; at that time, she was hospitalized for Pneumocystis pneumonia, which was when she was diagnosed with HIV and found to have AIDS.
MEDICATIONS: Trizivir one PO bid, which she has been on for 3 months (she is now adherent, though she says in the past she had not been)
Bactrim DS one PO M, W, F
Azithromycin q week
SOCIAL HISTORY: Lives with her boyfriend, a welder
She works as a waitress at the local IHOP
Smokes 3 packs/day cigarettes
Doesn't drink
FAMILY HISTORY: Unknown; ran away from home at age 13
REVIEW OF SYSTEMS: Occasional night sweats
Low-grade fevers every 3-5 days
Sore throat on occasion
Cough daily; especially in the morning
Loose stools daily; normal for her is 4-5 bowel movements daily; no blood
Vomiting on occasion
No rash
Decreased appetite
PHYSICAL EXAMINATION: Fairly well-appearing woman in no distress
BP 110/70, P 90, RR 14, Temp 99° F, Ht 5' 5", Wt 110
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple; no masses
Heart: RRR with no murmurs, rubs, or gallops
Lungs: Scattered rhonchi at bases; cleared with cough
Abdomen: Bowel sounds present; liver span 10 cm; no spleen palpated
Extremities: No cyanosis, clubbing, or edema
Skin: Facial acne; no other rashes
LABORATORY:
WBC: 2,400 with 70% lymphs, 20% neutrophils
Hgb:
12.5 mg/dL; MCV 105
Platelets: 450,000
Electrolytes: Normal
Albumin:
3.4 mg/dL
AST: 30 U/L
ALT: 25 U/L
Total bilirubin: 0.4 mg/dL
Viral load: < 50 copies/mL
CD4: 50
She is due for her tuberculosis screening; which of the following do you recommend?
a) PPD containing 5 TU of tuberculin with 2 controls (mumps and Candida)
b) PPD containing 250 TU of tuberculin without controls
2-step boosted PPD with 5 TU of tuberculin (place one today and repeat in 2 weeks)
c) PPD containing 5 TU of tuberculin without controls
d) PPD containing 250 TU of tuberculin with 2 controls (mumps and Candida)
Your next patient is an 18-year-old woman who is HIV-infected. Her most recent CD4 count was 10. She is moving to your area from Iowa. She says she had a TB skin test 2 years ago and some other skin tests, all of which were read as 0 mm. She remembers that the doctor there told her to tell people the number was "0 millimeters" and not "negative."

PAST MEDICAL HISTORY: She has not required hospitalization in 3 years; at that time, she was hospitalized for Pneumocystis pneumonia, which was when she was diagnosed with HIV and found to have AIDS.
MEDICATIONS: Trizivir one PO bid, which she has been on for 3 months (she is now adherent, though she says in the past she had not been)
Bactrim DS one PO M, W, F
Azithromycin q week
SOCIAL HISTORY: Lives with her boyfriend, a welder
She works as a waitress at the local IHOP
Smokes 3 packs/day cigarettes
Doesn't drink
FAMILY HISTORY: Unknown; ran away from home at age 13
REVIEW OF SYSTEMS: Occasional night sweats
Low-grade fevers every 3-5 days
Sore throat on occasion
Cough daily; especially in the morning
Loose stools daily; normal for her is 4-5 bowel movements daily; no blood
Vomiting on occasion
No rash
Decreased appetite
PHYSICAL EXAMINATION: Fairly well-appearing woman in no distress
BP 110/70, P 90, RR 14, Temp 99° F, Ht 5' 5", Wt 110
HEENT: PERRLA, EOMI
TMs clear
Throat clear
Neck: Supple; no masses
Heart: RRR with no murmurs, rubs, or gallops
Lungs: Scattered rhonchi at bases; cleared with cough
Abdomen: Bowel sounds present; liver span 10 cm; no spleen palpated
Extremities: No cyanosis, clubbing, or edema
Skin: Facial acne; no other rashes
LABORATORY:
WBC: 2,400 with 70% lymphs, 20% neutrophils
Hgb:
12.5 mg/dL; MCV 105
Platelets: 450,000
Electrolytes: Normal
Albumin:
3.4 mg/dL
AST: 30 U/L
ALT: 25 U/L
Total bilirubin: 0.4 mg/dL
Viral load: < 50 copies/mL
CD4: 50
She is due for her tuberculosis screening; which of the following do you recommend?
a) PPD containing 5 TU of tuberculin with 2 controls (mumps and Candida)
b) PPD containing 250 TU of tuberculin without controls
2-step boosted PPD with 5 TU of tuberculin (place one today and repeat in 2 weeks)
c) PPD containing 5 TU of tuberculin without controls
d) PPD containing 250 TU of tuberculin with 2 controls (mumps and Candida)