Aoa Pulm Review Notes

7/28/2019 Aoa Pulm Review Notes

1/6

High-Yield Review for the

Pulmonary/Allergy/ENT Module Exam and

USMLE Step 1

Matthew Warndorf, M4

Nicholas Detore, M4

January 16, 2009

Notes from the presentation

1. A woman in her 30s with dyspnea for several years. No cough or sputum.Hyperresonance to percussion. CT with decreased attenuation throughout.

a. Alpha 1 antitrypsin deficiencyb. Lab finding is decreased serum alpha 1 antitrypsinc. Panacinar emphysema (thus decreased attenuation throughout on CT)d.

May also have cirrhosis of livere. Phenotype is PI ZZ

2. A man previously treated with penicillin receives an IM dose of the drug andquickly develops hypotension and shock.

a. Anaphylaxisb. IgE-mediatedc. IgE bound to mast cell, reexposure to antigen cross-links Igerelease of

mediators3. A week post-op from surgery for cancer an elderly woman walks to the bathroom

and upon returning to bed gets suddenly dyspneic and diaphoretic with chest pain.

a. Pulmonary embolusb. Usually from DVT (leg/pelvic vein), can come from right atrium (atrial

fib), thrombogenic catheters

c. Risk factors are immobilization, cancer, fracture (recall Virchows triad)d. Usually CT angiography, can also do V/Q scan. Gold standard is

pulmonary angiography (invasive)

e. Saddle embolus is large clot that lodges at main PA bifurcationf. Pulmonary infarction can be a complication of PE (pleural-based, wedge-

shaped)

4. A young girl suddenly develops wheezing and coughs up a mucus plug. Has hadsymptoms like this before. Chest is quiet on auscultation. CXR shows

hyperinflation.a. Asthma, a chronic inflammatory disease of the airwaysb. Reversible (increase in FEV1 of 12% or 200mL)c. Triggers: URI, smoke, allergens, stressd. Treatment mainstay is short acting B agonist (albuterol). Any persistent

asthma should have a controller (like an inhaled corticosteroid).

i. B2 agonistsalbuterol (short), salmeterol (long) [remember,B1=heart, B2=lung], relax bronchial smooth muscle

ii. Muscarinic agentsIpratropium (block muscarinic receptors)


2/6

iii. MethylxanthinesTheophylline, narrow therapeutic indexiv. CorticosteroidsPrednisone (inhibit the synthesis of virtually all

cytokines)v. Leukotriene inhibitorsZileuton, zafirlukast/montelukast

e. Obstructive vs. Restrictive Diseasei.

Obstructive: decrease inFEV1, increased or normal FVC,decreased FEV1:FVC ratio1. Common examples are COPD and asthma2. In general, asthma=reversible; COPD=not fully reversible

ii. Restrictive: decrease in FEV1 andFVC, normal or increasedFEV1:FVC ratio

1. Common example is IPF2. Smaller lung volumes and they desaturate with exertion

5. A young man with hemoptysis, edema, hypertension, hematuria, proteinuria andRBC casts.

a. Goodpasture syndromeb.

Type II hypersensitivity reactionc. Antibodies against basement membrane leads to recurrent pulmonaryhemorrhage and glomerulonephritis

d. Treatment options are limited: steroids, plasmapheresis,immunosuppressive medicines

6. A young, previously health female with fever, nasal discharge with purulence,anosmia, and complains of facial pressure and pain, especially over the frontal

bone and bridge of the nose. Symptoms have persisted for 10 days.a. Acute sinusitisb. Often presents as unrelenting progression of a viral URI or allergic rhinitis

beyond the normal 5 to 7 day course.

c. Periorbital pressure/pain, nasal obstruction, mucopurulent discharge,fatigue, fever, headache.

d. Thought to be 2o to decreased ciliary action of the sinus mucosa andedema causing obstruction of the sinus ostia.

e. Most common bacterial causes are Strep pneumoniae, Staph aureus, H.influenzae.

f. Treatment: amoxicillin, TMP/SMX7. A 60 year-old man with a 60 pack-year smoking history presents with hemoptysis

and weight loss. Sputum exam shows atypical cells. Serum calcium is elevated.

Where is the lesion?

a. Likely a large hilar mass, a squamous cell carcinoma (assoc. with PTH-rpand thus the hypercalcemia)

b. Central tumors (think of central tumors with a paraneoplastic syndrome)i. Squamous, clear link to Smoking, ectopic PTH-related peptide

(incr. Ca++)ii. Small cell, clear link to Smoking, ectopic hormone production

(ADH, ACTH). Lambert-Eaton Syndrome (Abs against NM

junction Ags, similar to MG)c. Peripheral tumors


3/6


4/6

12.A child returns from vacation in Florida with complaints of earache and whitishdischarge from the ear. No fever/chills/URI symptoms.

a. Otitis Externa (Swimmers Ear)b. Generalized infection of external ear canal and often the tympanic

membrane.

c.

Characterized by ear pain (otalgia), swelling of external ear, ear canal, orboth; erythema; pain on manipulation of the auricle; debris in canal;otorrhea.

d. Often associated with prolonged water exposure and damaged squamousepithelium of the ear canal (i.e. swimming, hearing aid use).

e. Most frequently caused by Pseudomonas.f. Malignant otitis externa in diabeticsg. Treatment: keep ear dry, remove debris if present, local steroid and

antibiotic drops (polymyxin, bacitracin, neomycin), analgesics.13.A young man in involved in an MVC leading to blood loss and prolonged

hyptension. He is placed on a ventilator. He has increasing O2 and PEEP

requirements but remains afebrile. He dies after 4 days.a. ARDSb. Pathology similar to neonatal respiratory distress syndrome/hyaline

membrane disease

c. Proteinaceous fluid leaks into alveolid. The final event following lung injury from a variety of serious illnesses or

accidents (shock, trauma, sepsis, aspiration)

e. Clinicallyi. Acute onset

ii. Hypoxemiaiii. Bilateral pulmonary infiltrates on CXRiv. Absence of primary left heart failureNONCARDIOGENIC

pulmonary edema

f. Mechanical ventilation, PEEP14.A NEOUCOM student falls asleep under a tree on a cold night and wakes with

right facial weakness. There are no signs of stroke after evaluation at the ED.

a. Bells Palsyb. Sudden onset, unilateral facial weakness or paralysis in absence of CNS,

ear, or cerebellopontine angle disease (i.e. no identifiable cause).

c. Pathogenesis: unknown, although accepted hypotheses include viraletiology (i.e. herpes virus) and long term exposure to cold.

d. Pathology: related to swelling of facial nerve (CN VII)e. Treatment: usually none is required, as most cases spontaneously resolve

in ~4 weeks, protect eye with drops, some ENTs advocate steroids and

acyclovir.

f. Oveall 90% of patients recover completely.15.A young child has sudden onset of dyspnea and wheezing after being left alone to

play with her toys. On exam she has absent breath sounds on the right.

a. Foreign body aspirationb. All that wheezes is notasthma!


5/6

c. More commonly right mainstemless acute angled. Review V/Q mismatch and why 100% FiO2 will not fully correct the

ABG disturbance in this child (the same as a child with congenital heartdisease like TOF of Transposition that is chronically hypoxic). This is

shunt, the opposite of physiologic dead space.

16.A 70-year-old man has had dyspnea for a year. He worked in construction all hislife. CXR shows pleural plaques. Sputum cytology shows no atypical cells.FVC is reduced but FEV1/FVC is normal.

a. Asbestosisb. Diffuse pulmonary interstitial fibrosis caused by inhaled asbestos fibers.c. Risk of pleural mesothelioma (thirty years later) and bronchogenic

carcinoma.

d. Ferruginous bodies in lung (asbestos fibers coated with hemosiderin,phagocytosed by macrophages)

e. Ivory-white pleural plaquesf. Shipbuilders and plumbers.

17.A 2-year-old girl with respiratory distress. Low-grade fever, inspiratory wheeze,retractions, barking cough. This developed a few days after a URI.

a. Croup (Laryngotracheobronchitis)b. Parainfluenza viral infection of the larynx and trachea, generally affecting

children and seen most often in autumn months.c. Causes respiratory distress, low-grade fever, and steeple sign on A-P

neck x-ray indicating subglottic narrowing.

d. Classic symptom is barking seal-like cough.e. Treatment: keep child calm, aerosolized racemic epinephrine, cool mist,

and steroids.

18.A 70-year-old woman develops fever, dyspnea and sputum production and isfound to have a RLL infiltrate on CXR. She is in ill health and her family decidesnot to treat her acute illness. She dies four days later.

a. Pneumoniab. LobarCommonly pneumococcus. Intra-alveolar exudate

consolidation. Red, then grey hepatization Fever, chills, malaise, sputum,

hemoptysis.

c. BronchopneumoniaS. Aureus, H. Flu, Klebsiella, S. Pyogenes. Elderly,infants. Acute inflammatory infiltrates from bronchioles into adjacent

alveoli, patchy distribution over 38C or < 36C2. Heart rate > 90 beats/min


6/6

3. Respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg4. WBC count > 12,000/mm3 , < 4000/mm3 , or > 10%

immature (band) formsii. SepsisSIRS in response to infection (i.e., there is a known

source)

iii.

Severe sepsisAssociated hypotension/ hypoperfusion/organdysfunction (oliguria, AMS, lactic acidosis)iv. Septic shockSepsis-induced hypotension despite adequate fluid

resuscitation

v. MODSPresence of altered organ function in an acutely illpatient such that homeostasis cannot be maintained without

intervention.

19.Sourcesa. Lange Q&A for USMLE Step 1, 6th Ed. McGraw-Hill 2008b. First Aid Q&A for USMLE Step 1, McGraw-Hill 2007c. First Aid For USMLE Step 1, McGraw-Hill 2006d.

Webpathi. http://library.med.utah.edu/WebPath/webpath.html

Documents

Aoa Pulm Review Notes