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69yo M is eval'ed for COPD. Meds are tiotropium, fluticasone/salumetrol, albuterol inhalers. What rx would reduce COPD exacerbations?
- roflumilast is a selective PDE-4 inhibitor and used as add on therapy in severe COPD assoc w/chronic bronchitis and hx of recurrent exacerbations to reduce risk and freq of exacerbation
72yo M was seen in ER 2 wks ago for sudden onset CP. CTPE neg for PE but showed 8mm ground glass nodule in RUL. Followup CT at 12mths and 2 yrs with unchanged nodule. Most appropriate management?
chest CT scans every 2 years for 5 years
- subsolid lung nodules 6-8mm in size should be initially followed up at 6-12 mths and then every 2 years for 5 yrs because of slow rate of growth if such masses are malignant
62yo M w/sleep apnea. What is the strongest indication for positive airway pressure therapy?
excessive daytime sleepiness
- strongest indication for treatment of OSA
46yo M w/problems auto-adjusting positive airway pressure prescribed for OSA. On exam has boggy erythematous nasal mucosa. Rx?
- common complication of PAP therapy is dessication of nasal mucosa by forced air
- in line heated humidification is simple intervention to mitigate mucosal irrigation
49yo F w/recent hospitalization for asthma exacerbation, continues to have intermittent wheezing. 2 other hospitalizations for the same thing. Meds are mometasone/formoterol, monteleukast, albuterol, tiotropium, and pred. WBC 10K, 650 eos. IgE 12. Rx?
initiate trial of mepolizumab therapy
- in pts w/moderate to severe uncontrolled asthma w/eosinophilic phenotype, treatment with mepolizumab can reduce ER visits, hospitalizations, and use of steroids
71yo M seen as f/u for sleep related breathing pauses when admitted for ICD. PSG shows central sleep apnea w/Cheyne Stokes breathing pattern. Rx?
- initial treatment of central sleep apnea should target modifiable risk factors; medical optimization of heart failure has been shown to improve central sleep apnea and Cheyne Stokes breathing
58yo M w/hx severe COPD has chronic exertional dyspnea. Chest CT shows heterogeneous emphysema w/o any nodules. Management?
eval for lung volume reduction surgery
- lung volume reduction surgery improves quality of life and survival for pts w/upper lobe predominant emphysema and significant exercise limitations
72yo F w/30 pack yr smoking hx and quit 5 years ago. Screening low dose CT scan shows peripheral 9mm solid pulm nodule in LUL and emphysema. PET FDG performed and nodule intensely hypermetabolic. Most appropriate management?
surgical wedge resection
- solid indeterminant lung nodule >8mm and high prob of malignancy should be staged with PET/CT then definitive management
73yo M eval'ed for 6mth hx of R sided chest discomfort, fatigue, nonproductive cough, progressive dyspnea. Lost 20lbs last 6 mths. Hx of COPD and was brake mechanic for 6 yrs. CXR w/moderate R side loculated effusion w/pleural thickening. Thora removes 600mL serosanguinous fluid w/atypical mesothelial cells, LDH 425, pH 7.35, Tprot 4.6. Dx?
malignant pleural mesothelioma
- asbestos exposure is primary risk factor
- most pts commonly present w/chest pain and slowly enlarging pleural effusion
54yo M eval'ed after emergency appy 1 mth ago. Has ALS, on nocturnal O2. ABG 7.42/53/53/33. FVC 49%. Management?
bilevel positive airway pressure
- biPAP augments ventilation by providing pressure support, improves quality of life, and may prolong survival in ALS
32yo F eval'ed for 10 day hx of severe cough w/sputum, fever, wheezing. Has 12yr hx of abd pain, watery stools, sinusitis. FEV/FVC 0.55. Underlying dx?
- conditions suggesting the dx of CF in adults include chronic asthma like sx, chronic sinusitis, nasal polyposis, recurrent pancreatitis, infertility, bronchiectasis
30yo M w/hx of EtOH and drug abuse was found unresponsive and intubated. Utox +EtOH, benzos. Management?
monitor for signs of agitation
- treatment for benzo overdose is supportive w/assurance of adequate ventilation
- flumazenil is generally not recommended for benzo overdose as it can precipitate seizures in chronic users and short half life makes it difficult to sustain reversal
38yo M w/6mth hx of DOE. Has GERD and Raynaud's. Has telengiectasias and sclerodactyly. DLCO 43%. Dx?
- pt has systemic sclerosis and pulm arterial HTN commonly assoc w/this
72yo F eval'ed for pneumothorax. Severe, O2 dependent COPD. Had L chest tube placed. Management?
- recurrence prevention w/pleurodesis is recommended after the first occurrence of secondary spontaneous PTX
70yo M has 4 wk hx of dyspnea, orthopnea, daytime sleepiness. Dx ALS 6 mths ago. CXR w/bilateral basal opacities c/w atelectasis and shallow inspiration. Rx?
NIV with biPAP
- biPAP improves survival and quality of life in pts w/neuromuscular disease
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