Question 1

A 46-year-old previously healthy man comes to the hospital due to a day of pleuritic chest pain and dyspnea.  The patient has had right leg swelling for the past week.  He has smoked a pack of cigarettes daily for 12 years and works as a truck driver.  Cardiopulmonary examination is within normal limits with the exception of tachycardia.  The right lower extremity is swollen and tender up to the mid thigh.  CT pulmonary angiography shows a right-sided pulmonary embolism, and duplex venous ultrasound reveals a thrombus in the right femoral vein.  The patient is admitted to the hospital and started on low-molecular-weight heparin therapy.  During morning rounds, he suddenly becomes unresponsive and has no palpable pulses despite electrical activity consistent with sinus bradycardia at 50/min on the cardiac monitor.  Advanced cardiac life support measures, including external chest compressions and endotracheal intubation, are implemented.  After 4 minutes of chest compressions, he is still pulseless and the monitor shows sinus bradycardia.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c079_c96d_8f63_2fd3cddfe560_MD0005_00 This unresponsive patient has experienced cardiac arrest, with the cardiac monitor showing pulseless electrical activity (PEA). PEA is defined as an organized cardiac rhythm that is unable to generate sufficient cardiac output to create a measurable blood pressure or palpable pulse. Cardiac arrest due to either PEA or asystole (complete absence of cardiac electrical and mechanical activity) is managed the same based on the advanced cardiac life support protocol. Immediate cardiopulmonary resuscitation (CPR) consisting of effective chest compressions and assisted breathing should be administered. In addition, epinephrine 1 mg should be administered via the intravenous or intraosseous route every 3-5 minutes in an effort to increase organ and tissue perfusion. Shocks (defibrillation attempts) are not administered for cardiac arrest due to PEA or asystole. CPR should continue uninterrupted while attempts are made to identify and treat potentially reversible causes of PEA. This patient's PEA cardiac arrest is most likely due to a recurrent acute pulmonary embolism, and administration of tissue plasminogen activator with ongoing CPR likely provides the best chance of restoring a perfusing cardiac rhythm. causes (Choice A) Intravenous atropine is indicated in patients with symptomatic bradycardia (eg, hypotension, heart failure); however, sinus bradycardia in the absence of a pulse represents PEA rather than symptomatic bradycardia. Atropine is not used in patients with PEA cardiac arrest. (Choices B and D) Intravenous calcium gluconate is sometimes helpful for patients with cardiac arrest due to hyperkalemia, and sodium bicarbonate may be helpful in patients with cardiac arrest due to hyperkalemia, metabolic acidosis, or tricyclic antidepressant overdose. However, unless there is a high suspicion for such underlying causes, these agents should not be administered prior to epinephrine. (Choice E) Cardiac pacing is ineffective in patients with PEA or asystole cardiac arrest and is not recommended. Educational objective: Cardiac arrest due to pulseless electrical activity or asystole should be managed with prompt, uninterrupted cardiopulmonary resuscitation along with epinephrine every 3-5 minutes and early identification and treatment of potentially reversible causes. Atropine and cardiac pacing are not used for the treatment of pulseless electrical activity or asystole. References: Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. (http://www.ncbi.nlm.nih.gov/pubmed/20956224)

Question 2

A 16-year-old girl comes to the office with shortness of breath. She has not been able to participate in weekly soccer practice for the last few months due to dyspnea and chest tightness. Her symptoms start 10-15 minutes after beginning exercise and last about 30 minutes, but she is asymptomatic at other times. The patient has no known medical problems. Her brother has ostium secundum atrial septal defect and her mother has allergic rhinitis. Vesicular breath sounds are heard on lung examination. Cardiac auscultation reveals normal splitting of second heart sound in the left upper sternal border during inspiration and no murmurs. Jugular venous pressure is estimated at 5 cm H₂O. There is no lower extremity edema. Which of the following is the most appropriate next step in managing this patient?

Accepted Answer

Explanation: This patient's symptoms suggest exercise-induced bronchoconstriction (EIB). EIB may occur in asthmatics or in patients without a pre-existing diagnosis of asthma. Bronchial smooth muscle constriction may be triggered by exertion or passage of large volumes of dry cold air causing mast cell degranulation. Patients with EIB may be otherwise asymptomatic. Clinical symptoms are not sufficient to make a diagnosis of EIB, and bronchoprovocation testing with exercise or inhalation of dry, cold air is recommended. A fall in forced expiratory volume in 1 second of >10% is considered positive; a fall >15% is diagnostic. Pre-exercise warm-up may be sufficient to prevent EIB in those with only occasional symptoms. Patients with persistent symptoms who exercise infrequently (less than daily) requireshort-acting β2-agonists (SABAs) 10-20 minutes before exercise. Mast cell stabilizers (cromolyn sodium or nedocromil) may be used in patients who do not tolerate SABAs. Athletes who exercise frequently should be started on daily inhaled corticosteroids with SABAs as needed (Choice B). (Choice C) Echocardiogram with bubble study will diagnose structural heart disease and septal defects. Symptomatic septal defects produce fixed splitting of the second heart sound and possibly audible murmurs, which are detectable on examination. This patient has normal cardiac examination findings. (Choice D) Exertional dyspnea may be caused by any etiology of interstitial lung disease. Crackles are usually heard on lung examination in these patients. A high-resolution chest CT scan may be helpful in diagnosing these disorders. However, this patient has a completely normal lung examination. (Choice E) Exertional dyspnea with chest tightness in this age group is concerning for left ventricular outflow tract (LVOT) obstruction. Patients with symptomatic LVOT obstruction will likely have a systolic murmur that accentuates with Valsalva maneuver. Stress testing is used in the risk stratification of LVOT obstruction. Educational objective: Exercise-induced bronchoconstriction (EIB) can occur with or without pre-existing asthma. Diagnosis is made with bronchoprovocation testing. Treatment includes pre-exercise warm-up for infrequent EIB, short-acting β2-agonists for persistent symptoms, and daily inhaled corticosteroids for those requiring daily β2-agonist therapy. References: Exercise-induced bronchospasm diagnosis in children. utility of combined lung function tests. (http://www.ncbi.nlm.nih.gov/pubmed/25444583) Diagnostic exercise challenge testing. (http://www.ncbi.nlm.nih.gov/pubmed/21915675)

Question 3

A 6-month-old boy is brought to the emergency department by his mother during the winter due to 3 days of nasal discharge and cough.  His mother states, "He hasn't been breastfeeding well today because he's so congested."  The infant has been voiding adequately and has had no vomiting, diarrhea, or skin rash.  His older brother attends preschool and is recovering from an upper respiratory illness.  The patient has no prior illnesses and no known allergies, and all vaccinations are up to date.  He was born at term via an uncomplicated delivery and has met all developmental milestones appropriately.  Temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, pulse is 150/min, and respirations are 50/min.  Pulse oximetry shows an oxygen saturation of 93% on room air.  Examination reveals moderate respiratory distress with subcostal retractions, coarse breath sounds, and expiratory wheezing bilaterally.  Oral mucous membranes are dry, but capillary refill is <2 seconds.  The patient is admitted to the hospital and placed on appropriate infection-control precautions. Two days later, the patient remains afebrile, and pulse oximetry has been consistently >97% on room air.  Weight has decreased 6 oz (0.17 kg) from admission, but the patient is now breastfeeding well every 3-4 hours.  Examination shows crusted rhinorrhea at the nares and no grunting, nasal flaring, or retractions.  The lungs are clear to auscultation.  The patient is stable for discharge home, but his parents are concerned about his prognosis.  The infant is at greatest risk for developing which of the following?

Accepted Answer

Explanation: Symptoms of respiratory syncytial virus (RSV) bronchiolitis typically peak around day 3-5 of illness. Infants age <2 months are at greatest risk of apnea and respiratory failure. Older, full-term, healthy infants and young toddlers typically recover with no complications. However, RSV is associated with the development of recurrent wheezing in up to 30% of patients. Patient should be advised to avoid other triggers of airway reactivity, particularly exposure to secondhand cigarette smoke. (Choice A) As in this patient, bronchiolitis may cause dehydration and weight loss. However, after resolution of acute infection and resumption of normal feeding, weight gain and growth are expected. (Choice B) In contrast to patients with cystic fibrosis, immunodeficiency, or other underlying lung disease, bacterial pneumonia is an unlikely complication in patients with RSV bronchiolitis. (Choice C) RSV bronchiolitis is not a risk factor for fungal disease (eg, Aspergillus) in an otherwise healthy host, in contrast to patients with cystic fibrosis or immunodeficiency. (Choice E) Spontaneous pneumothorax (the presence of air in the pleural cavity) is a rare, life-threatening complication of chronic or acute lung disease. This is an unlikely complication in this patient demonstrating recovery from the acute infection. Educational objective: Respiratory syncytial virus bronchiolitis is associated with recurrent wheezing. Patients should be advised to avoid other triggers of airway reactivity, particularly cigarette smoke. References: Apnea in children hospitalized with bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/24101759) Respiratory syncytial virus and recurrent wheeze in healthy preterm infants. (http://www.ncbi.nlm.nih.gov/pubmed/23656644)

Question 4

A 60-year-old man with a history of chronic obstructive pulmonary disease comes to the office due to hemoptysis.  For the past several days, he has had increasing cough with greenish-yellow sputum.  He also had 2 episodes of blood-streaked sputum, which prompted the clinic visit.  The patient has mild dyspnea but no fever or chest pain.  His other medical problems are peripheral vascular disease and osteoarthritis.  His current medications include aspirin, inhaled fluticasone and salmeterol, and ipratropium.  He continues to smoke 1/2 pack of cigarettes daily and drinks alcohol occasionally.  The patient had a screening CT scan 2 years ago that was negative for lung mass.  His father died of lung cancer.  Blood pressure is 140/95 mm Hg and heart rate is 100/min.  The patient's pulse oximetry shows 95% on room air.  Lung auscultation reveals bilateral expiratory wheezing. The initial workup reveals no significant abnormality.  The patient is started on glucocorticoid therapy and additional inhaled albuterol.  Which of the following is the best next step in management?

Accepted Answer

Explanation: This patient's presentation (cough productive of greenish-yellow sputum, dyspnea, and wheezing) and history of chronic obstructive pulmonary disease (COPD) are suggestive of acute COPD exacerbation. Antibiotics are generally not recommended for management of acute bronchitis in otherwise healthy individuals as most exacerbations are of viral etiology. However, guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend antibiotic therapy for patients who have a COPD exacerbation with any two of the following features: increased sputum purulence, increased sputum volume, or increased dyspnea. Antibiotics are also recommended for those requiring mechanical ventilation (noninvasive or invasive). (Choice A) Inpatient management of COPD exacerbation is indicated only for those who fail outpatient therapy or have severe symptoms (eg, rapidly worsening dyspnea, worsening hypoxia/hypoxemia, altered mental status, forced expiratory volume in 1 second <50% predicted). (Choices B and E) No clear benefit has been seen with expectorant agents (eg, N-acetylcysteine) or systemic bronchodilators (eg, theophylline) over inhaled bronchodilators. (Choice C) Supportive care should include adequate hydration, glucocorticoids, and bronchodilation. Educational objective: Acute bronchitis is the most common cause of hemoptysis. A trial of antibiotic therapy is warranted in patients with increased dyspnea, increased sputum volume, or increased sputum purulence.

Question 5

A 67-year-old man comes to the emergency department due to 3 days of fever and cough productive of yellowish sputum.  He has had no hemoptysis, weight loss, night sweats, or anorexia.  He has not traveled recently and has not had exposure to anyone with similar symptoms.  The patient was discharged from the hospital 3 weeks ago after an episode of community-acquired pneumonia involving the left lower lobe.  He is a chronic smoker with a 45-pack-year smoking history.  He drinks alcohol occasionally.  Temperature is 38.1 C (100.6 F), blood pressure is 112/52 mm Hg, pulse is 98/min, and respirations are 22/min.  Oxygen saturation is 90% on room air.  Physical examination reveals decreased breath sounds and crackles over the left lower lobe.  Chest x-ray is consistent with consolidation of the left lower lung zone.  What is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient's fever, productive cough, tachypnea, hypoxia, and left lower lobe crackles are all likely due to a left lower lobe pneumonia as demonstrated by the area of consolidation on the chest radiograph. The complicating factor is that the patient had a pneumonia in the same location only 3 weeks ago. The most appropriate next test in the workup is further chest imaging with a CT scan. Given his extensive smoking history, the most concerning possibility is the presence of an obstructing endobronchial neoplasm leading to a nonresolving pneumonia. Such masses can be difficult to detect amidst the area of consolidation on chest radiographs, but chest CT can be helpful in making the diagnosis. Chest CT would also show a lung abscess or empyema, which could also be contributing to the failure of this patient's symptoms to resolve. Other possible causes of treatment-resistant pneumonia include bacterial resistance, other pathogens such as tuberculosis or fungus, immune dysfunction, or noninfectious neoplastic or inflammatory conditions mimicking pneumonia. If the chest CT is not helpful, bronchoscopy may be needed. Open lung biopsy would only be considered if both chest CT and bronchoscopy were nondiagnostic (Choice D). (Choice B) Although an immune deficiency can result in a nonresolving pneumonia, the patient's advanced age makes congenital causes unlikely. Furthermore, this patient has no clear risk factors for HIV. Chest CT would be a much better test at the current time. (Choice C) Lack of night sweats, weight loss, and hemoptysis makes tuberculosis less likely. Obtaining material for mycobacterial cultures, possibly by bronchoscopy, could be considered if CT supports the possibility of mycobacterial infection. (Choice E) Chronic obstructive pulmonary disease from smoking could be a factor in delayed resolution of pneumonia in this patient, but the greater concern is the presence of an obstructing malignancy. As such chest CT would be the most appropriate next test. Educational objective: An obstructing endobronchial malignancy should be suspected in patients with an extensive smoking history who have nonresolution of a pneumonia. A chest CT can help to diagnose such a malignancy as well as other causes of a nonresolving pneumonia such as an abscess or empyema.

Question 6

A 10-year-old boy is brought to the clinic by his adoptive parents due to a worsening cough.  The patient has had a productive cough with yellow-green sputum since his parents adopted him at age 7 from a developing country.  A tuberculin skin test at the time of immigration revealed a 3-mm induration.  The patient's cough has worsened over the past 3 days, and this morning he had a fever of 38.3 C (101 F).  His parents kept him home from school, and he has been resting in bed.  The patient has been hospitalized twice in the past year for pneumonia.  Temperature is 38.1 C (100.6 F).  Height and weight, which were at the 25th percentile 2 years ago, are now at the 5th percentile.  The patient is a thin, cooperative child in no acute distress.  Auscultation of the lungs reveals scattered bilateral rhonchi and wheezes.  Cardiac examination reveals a regular rhythm and no murmurs.  The abdomen is soft and nontender with hard stool palpable in the right lower quadrant.  Chest x-ray reveals hyperinflation with increased bronchovascular markings throughout and several parallel linear opacities in the bilateral upper lobe parenchyma.  Which of the following would most likely establish the diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_c07d_4be0_8f63_4183f69224fc_MD0005_00 This patient has a chronic, productive cough, recurrent respiratory infections, and weight loss, suspicious for cystic fibrosis (CF). An autosomal recessive mutation affecting the CF transmembrane conductance regulator gene impairs chloride transport, resulting in abnormally thick secretions. In the lungs, viscous secretions allow bacteria (eg, Staphylococcus aureus, Pseudomonas aeruginosa) to colonize, predisposing the patient to frequent infection. Mucus plugs the airways and leads to hyperinflation from chronic obstruction and bronchiectasis, as seen on this patient's x-ray. Thick intestinal secretions leave the gastrointestinal tract dehydrated and prone to constipation (as seen in this patient with stool palpable in the right lower quadrant) and obstruction. In addition, mucus blocks the pancreatic ducts and impairs enzyme secretion, resulting in malabsorption, failure to thrive, and often CF-related diabetes. x-ray CF is being increasingly recognized in different parts of the world. Newborn screening frequently identifies patients with CF in the United States; however, this patient was born in a developing country and was likely not screened. The sweat chloride test is the gold standard for detecting CF, and 2 elevated sweat chloride levels in a symptomatic patient are diagnostic. (Choices A and D) Adenosine deaminase activity is reduced in a common form of severe combined immunodeficiency (SCID). SCID and HIV cause failure to thrive and severe bacterial, fungal (eg, Pneumocystis jirovecii, Candida), and viral (eg, herpes simplex virus, cytomegalovirus, Epstein-Barr virus) diseases. However, SCID typically presents within the first few months of life, and both SCID and HIV tend to be associated with infectious diarrhea rather than constipation. (Choice B) Dihydrorhodamine 123 oxidation test is diagnostic for chronic granulomatous disease, an X-linked immune disorder characterized by severe bacterial and fungal pneumonias and skin infections. Chronic granulomatous disease is unlikely in this child with no history of abscesses. (Choice C) Quantitative immunoglobulins are low in patients with common variable immunodeficiency. Recurrent infections and bronchiectasis are common; however, diarrhea, rather than constipation, would be expected. Educational objective: Cystic fibrosis should be suspected in children with recurrent respiratory infections, bronchiectasis, constipation, and failure to thrive. The sweat chloride test is the gold standard for diagnosis. References: The diagnosis of cystic fibrosis. (http://www.ncbi.nlm.nih.gov/pubmed/28576637)

Question 7

A 60-year-old Caucasian male presents to your office because of recent onset dyspnea on exertion.  He is physically active, but his dyspnea now restricts his physical activities.  He can hardly climb a flight of stairs without having to stop to rest.  He denies any chest pain, palpitations, leg swelling and loss of consciousness.  He has frequent coughing, sometimes with yellowish or greenish sputum.  He has been smoking one-and-half to two packs of cigarettes daily for the last 35 years.  He does not consume alcohol.  He is currently not taking any medications.  The physical examination is significant for bilateral scattered expiratory wheezes.  Pulmonary function testing shows the following findings (as percentage of predicted values):  His airway response to bronchodilators is poor.  What is the best indicator of this patient's poor prognosis?

Accepted Answer

Explanation: This patient has manifestations of advanced chronic obstructive pulmonary disease (COPD). A FEV1 below 40% of predicted indicates severe obstruction. The prognosis of patients with COPD varies with each individual. The two most important predictors of survival are FEV1 and age. After adjusting for age, FEV1 remains as the single most important factor in determining the prognosis. (Choices B, C and D)Other prognostic indicators described in several studies are airway responsiveness, cigarette smoking, decreased exercise capacity, decreased BMI, airway bacterial load and HIV status. (Choice E)Although increased residual volume is characteristic for COPD, it has little prognostic value. Educational Objective: After adjusting for age, FEV1 remains as the single most important factor in determining the prognosis of patients with COPD.

Question 8

A 72-year-old woman is found to be severely short of breath at her skilled nursing facility. The patient was recently hospitalized for vertebral osteomyelitis and discharged 2 weeks ago to complete a 6-week course of piperacillin-tazobactam via a peripherally inserted central venous catheter. Her dyspnea began only with exertion but is now also present at rest. Medical history includes coronary artery disease with ischemic cardiomyopathy, chronic obstructive pulmonary disease, and chronic kidney disease. She has had 2 hospitalizations for heart failure over the last year; noninvasive positive-pressure ventilation was required. Paramedics observe the patient to be obtunded with agonal respirations and rales throughout the bilateral lung fields. Oxygen saturation is 72% on room air. She is intubated and transferred to the emergency department. On arrival, the patient is minimally responsive to stimuli. Temperature is 36.7 C (98 F), blood pressure is 115/65 mm Hg, and pulse is 110/min and regular. The patient's oxygen saturation is 88% on 100% inspired oxygen. BMI is 19 kg/m². The trachea is midline. On physical examination, rales are heard on the right side and markedly decreased breath sounds on the left side of the chest. S3 is heard. There is 2+ bilateral peripheral edema. A chest x-ray reveals the following: Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient is in acute hypoxic respiratory failure likely due to an exacerbation of chronic heart failure. Because of rapid decompensation, she required endotracheal intubation in the field but has persistent hypoxemia following initiation of 100% supplemental oxygen. Complications can occur during any intubation procedure but are more common with field intubations due to the relatively uncontrolled environment outside of a medical facility. Therefore, it is important to confirm correct endotracheal tube (ETT) placement by checking for ETT depth, chest excursion, and bilateral breath sounds and by obtaining a chest x-ray. This patient's chest x-ray demonstrates right mainstem bronchial intubation (RMBI), a complication that results from excessive depth of ETT placement. Patients typically have respiratory distress due to hypoventilation, and breath sounds are diminished or absent on the left side. Retracting the ETT a few centimeters and rechecking placement typically leads to marked improvement in hypoxemia. In general, appropriate insertion depth for an ETT is 21 cm (8.3 in) for women and 23 cm (9 in) for men. (Choice A) Chest tube placement would be indicated if this patient had a left-sided hemothorax or pneumothorax. However, the chest x-ray shows large-volume atelectasis due to left lung collapse, so chest tube placement is not indicated. (Choice B) Although a chest CT scan may help further identify the underlying lung pathology and would demonstrate the positioning of the ETT, it is not appropriate for checking ETT placement due to the time required and unnecessary radiation exposure. (Choice C) Needle decompression at the midclavicular line of the second intercostal space is appropriate emergency treatment for a tension pneumothorax, a complication that can occur if RMBI is not corrected in a timely manner. Although patients with pneumothorax typically have absent breath sounds on the affected side, this patient's chest x-ray, which shows lung markings extending to the lung periphery, rules out significant pneumothorax. (Choice E) Dobutamine infusion is indicated for inotropic support in patients with cardiogenic shock. This patient's presentation is consistent with an acute exacerbation of heart failure (dyspnea, pulmonary edema on chest x-ray, lower extremity edema), and she may need inotropic support at some point; however, the RMBI should be addressed first. Educational objective: When endotracheal intubation has been used to secure the airway, it is important to confirm correct placement by checking endotracheal tube depth, chest excursion, and bilateral breath sounds and by obtaining a chest x-ray. References: The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians. (http://www.ncbi.nlm.nih.gov/pubmed/17312220) Impact of ATLS training on preventable and potentially preventable deaths. (http://www.ncbi.nlm.nih.gov/pubmed/24770906)

Question 9

A 27-year-old man comes to the emergency department with sudden onset of shortness of breath.  He ran out of his asthma medication 10 days ago.  He has been intubated twice in the past 6 months due to severe asthma exacerbations.  On physical examination, his temperature is 37.2 C (99 F), blood pressure is 142/64 mm Hg, heart rate is 110/min, and respirations are 28/min.  His oxygen saturation is 84% on room air and improves to 94% on nonrebreather mask.  The patient is alert but appears to be in respiratory distress with some use of accessory muscles of respiration.  His lung examination shows equal, bilateral air entry with diffuse wheezing throughout both lung fields.  His peak expiratory flow rate is 60% of his personal best, based on his prior admissions. While in the emergency department, the patient's respirations become more labored.  He is now markedly diaphoretic and has visible suprasternal retractions.  He appears exhausted and drowsy.  Repeat vital signs are temperature of 37.2C (99 F), blood pressure of 110/74 mm Hg, pulse of 106/min, and respirations of 10/min.  His oxygen saturation is 95% on nonrebreather mask.  Lung examination shows bilaterally equal but markedly reduced air entry with minimal wheezing on both sides.  The patient is not able to follow instructions to use the peak flow meter.  Which of the following is the most important next step in management?

Accepted Answer

Explanation: 11ec2b69_c075_0e77_8f63_897e582da143_MD0005_00 Response to therapy should be assessed periodically during the first few hours of treatment of an asthma exacerbation. Failure to recognize early signs of clinical deterioration and impending respiratory failure are responsible for the majority of morbidity and mortality seen in status asthmaticus. Clues to clinical deterioration include: Accessory muscle use with suprasternal retractions Cyanosis Diaphoresis Exhaustion or extreme fatigue Marked tachycardia Pulsus paradoxus PaCO₂ >42 mm Hg Peak expiratory flow (PEF) <25% of baseline These patients should be assessed immediately for impending respiratory failure. Ventilatory support should be considered early in the course of the disease. Signs of impending respiratory failure include: Confusion and drowsiness Depressed respiratory drive Severe hypoxemia Patients exhibiting any of these symptoms should be intubated immediately to secure and protect the airways. (Choices A, B, and C) Aggressive treatment with inhaled beta-2 agonists, inhaled ipratropium, and intravenous corticosteroids is the initial step in management of acute severe asthma exacerbation (PEF <40%). This patient also qualifies for intravenous magnesium as he has failed conventional therapy. However, with impending respiratory failure, immediate endotracheal intubation and mechanical ventilation should be performed as a priority without waiting for further medical therapy or admission to the hospital. (Choice E) Intravenous theophylline provides no effective bronchodilation in acute asthma exacerbation. Educational objective: Signs and symptoms of impending respiratory failure and status asthmaticus should be recognized early in asthma exacerbation. These patients should be intubated immediately to secure the airways. Inhaled beta agonists, inhaled ipratropium, intravenous glucocorticoids, and intravenous magnesium should also be given. References: Management of acute asthma in adults in the emergency department: assisted ventilation. (http://www.ncbi.nlm.nih.gov/pubmed/19901044)

Question 10

A 6-year-old girl is brought to the clinic due to a prolonged cough.  The patient started having rhinorrhea 6 weeks ago.  A week later, she developed a cough with occasional expectoration of whitish sputum; the rhinorrhea resolved at that time.  For the past 5 weeks, the patient's cough has continued throughout the day and night, occasionally awakening her and with no improvement.  Her father tried using a humidifier, with no relief of her symptoms.  The patient has been afebrile and has had no vomiting, abdominal pain, diarrhea, or sick contacts.  She takes no daily medications.  Immunizations are up to date.  The patient's mother has atopic dermatitis.  Height and weight are at the 25th percentile.  Temperature is 36.7 C (98 F) and respirations are 24/min.  The patient is awake, alert, and playing.  Tympanic membranes are normal.  The tonsils are normal, the mucous membranes are moist, and the lips are pink.  Cardiac examination has a normal rate and rhythm.  The lungs are clear to auscultation bilaterally; no retractions or use of accessory chest muscles are present.  Which of the following is the best next step in evaluation of this patient?

Accepted Answer

Explanation: Chronic cough in children is defined as a cough lasting >4 weeks. Initial evaluation includes a detailed history and thorough physical examination to potentially identify a specific underlying cause. For example, poor growth may suggest a chronic illness (eg, cystic fibrosis [CF]) or peripheral edema may suggest cardiovascular disease. In the absence of specific historical (eg, concomitant upper respiratory symptoms) or examination findings, initial evaluation begins with spirometry. Spirometry is a simple pulmonary function test that can be performed in a cooperative child to detect obstructive airway disease (eg, asthma). Cough due to asthma may be associated with wheezing, shortness of breath, or a history of atopy, as in this child with a family history of atopic dermatitis. However, isolated chronic cough with a normal lung examination may be the sole finding in asthma. Chest x-ray is also recommended for the evaluation of chronic cough. It may be helpful in identifying abnormalities such as mediastinal widening (eg, chronic infection, neoplasm), hyperinflation (eg, foreign body aspiration), or cardiac defects. (Choice A) CT scan of the chest in children is typically reserved to evaluate abnormal findings (eg, mass) found on less-invasive imaging (eg, x-ray) due to radiation exposure. This child warrants imaging if spirometry is normal, but x-ray is indicated first. (Choice B) Pertussis can present with a chronic cough following the paroxysmal stage and classically presents with a "whoop" in children age <10. Vaccinated children are less likely to develop pertussis and typically have a less severe illness. Pertussis testing could be considered if spirometry and imaging are normal. (Choice D) Sputum culture is obtained for patients with suspected active tuberculosis (TB). Although TB causes chronic cough, this patient has no risk factors (eg, high-risk travel, known contacts with TB) or other symptoms (eg, fever, weight loss) of TB. (Choice E) Sweat chloride testing is used in evaluation of CF. CF typically presents with failure to thrive, recurrent pulmonary infections, and pancreatic insufficiency (ie, steatorrhea). None of these symptoms are present in this patient. Educational objective: Chronic cough (>4 weeks) without specific historical or examination findings warrants spirometry testing to identify underlying obstructive lung disease (eg, asthma). References: Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/16428719)

Question 11

A 73-year-old man comes to the emergency department with fever and chest discomfort.  He was hospitalized with right lower-lobe pneumonia 3 months ago and improved with antibiotics.  He has since had an intermittent cough and a 4.5-kg (10-lb) weight loss.  The patient is a life-long nonsmoker.  He has a long history of Parkinson's disease with gait instability along with hypertension and acid-reflux disease.  His temperature is 38.3 C (101 F), blood pressure is 122/70 mm Hg, heart rate is 105/min, and respirations are 24/min.  Examination shows upper-extremity rigidity, resting tremor, mild dysarthria, and frequent drooling.  Lung examination shows crackles and dullness at the right base.  Extremities are warm to the touch.  The white blood cell count is 13,500/µL.  Chest x-ray shows a right middle-lobe infiltrate.  Intravenous antibiotics are started.  Which of the following tests is most helpful in evaluating this patient?

Accepted Answer

Explanation: 11ec2b69_c073_39b5_8f63_edd630dd8ac6_MD0005_00 This patient with underlying Parkinson's disease, oropharyngeal symptoms (dysarthria and drooling), and recurrent right-sided pneumonia has typical features of chronic aspiration. Nearly 90% of individuals with Parkinson's disease suffer from dysphagia during the course of the disease, and the resulting aspiration pneumonia is a leading cause of death. Aspiration pneumonia generally requires more aggressive intervention than typical community-acquired pneumonia. Aspiration often involves polymicrobial and anaerobic organisms, and patients with aspiration pneumonia often have poor underlying functional and nutritional status. Initial management includes blood and sputum cultures with initiation of broad-spectrum antibiotics with anaerobic coverage (eg, clindamycin). Once the patient has been stabilized, a bedside swallowing assessment may be helpful. Definitive diagnosis is made with a videofluoroscopic swallowing study. Based on results, a multidisciplinary dysphagia rehabilitation program can be initiated, usually with input from the dietary service, nursing, and speech therapy. Specific interventions typically include thickened liquids and modified swallowing techniques. (Choice A) Bronchoscopy can be useful in patients with recurrent pneumonia to rule out (and biopsy) endobronchial obstruction. This is especially helpful in patients with known or suspected malignancy. However, this patient shows features of aspiration. Although bronchogenic carcinoma may develop in nonsmokers, it is less likely. (Choice B) Computed tomography (CT) scan is frequently performed in patients with recurrent pneumonia to identify a mass lesion in the lung or airway. It can also help identify atypical infections as well as noninfectious pulmonary disorders. However, a CT scan would be unlikely to provide additional useful information in cases of suspected aspiration. (Choice C) Patients with hypogammaglobulinemia are at risk of recurrent infections due to encapsulated bacteria (eg, Streptococcus pneumoniae). Elderly patients with impaired nutrition may develop a secondary hypogammaglobulinemia, but this patient's pattern of right mid- and lower-lobe infections is more typical for aspiration. (Choice D) Pulmonary tuberculosis is a potential cause of persistent/recurrent lung infections in the elderly. In the majority of cases (>80%), however, tuberculosis will involve the upper/apical lung regions rather than the mid and lower lobes. Educational objective: A frequent complication of Parkinson's disease is the development of dysphagia and aspiration, which may be silent. Undetected dysphagia may lead to weight loss and frequent aspiration pneumonia. The diagnosis is confirmed with a videofluoroscopic swallowing study. A multidisciplinary intervention is required to address nutrition and reduce the risk of recurrent aspiration pneumonia.

Question 12

A 6-month-old boy is brought to the emergency department by his mother during the winter due to 3 days of nasal discharge and cough.  His mother states, "He hasn't been breastfeeding well today because he's so congested."  The infant has been voiding adequately and has had no vomiting, diarrhea, or skin rash.  His older brother attends preschool and is recovering from an upper respiratory illness.  The patient has no prior illnesses and no known allergies, and all vaccinations are up to date.  He was born at term via an uncomplicated delivery and has met all developmental milestones appropriately.  Temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, pulse is 150/min, and respirations are 50/min.  Pulse oximetry shows an oxygen saturation of 93% on room air.  Examination reveals moderate respiratory distress with subcostal retractions, coarse breath sounds, and expiratory wheezing bilaterally.  Oral mucous membranes are dry, but capillary refill is <2 seconds.  The patient is admitted to the hospital and placed on appropriate infection-control precautions. Which of the following is the most appropriate method of diagnosing this patient's condition?

Accepted Answer

Explanation: 11ec2b69_c078_b7fb_8f63_bb36aaff53bd_MD0005_00 Bronchiolitis is generally diagnosed clinically. Classic features include an upper respiratory prodrome of rhinorrhea, nasal congestion, and cough, followed 2-3 days later by lower airway signs of wheezing and increased work of breathing. Antigen testing of nasal or pulmonary secretions (Choice A) or nucleic acid amplification testing is used to detect breakthrough respiratory syncytial virus (RSV) infection among infants who receive palivizumab prophylaxis. In such patients, RSV infection provides active immunity and protection, and the palivizumab can be discontinued. (Choice B) Because bronchiolitis is a viral infection, blood cultures are not indicated, particularly due to the low rate of false-positive cultures for contaminant bacteria. In general, laboratory tests, including complete blood count and chemistry, are unnecessary in patients with bronchiolitis. (Choice C) Chest x-ray often reveals atelectasis and results in overdiagnosis of pneumonia and unnecessary antibiotic therapy. Complete blood count and chemistry are also unnecessary. (Choice E) Serology is generally not helpful in acute illness as it can take weeks for antibody titers to rise. Serology is also unreliable in infants age <6 months due to passively acquired maternal antibodies. Educational objective: The diagnosis of bronchiolitis is primarily clinical, and routine testing for respiratory syncytial virus (RSV) is unnecessary. If a decision is made to obtain viral testing, RSV antigens can be quickly detected in nasal or pulmonary secretions. References: Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/25349312) Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/22473882)

Question 13

A 27-year-old man comes to the emergency department with sudden onset of shortness of breath.  He ran out of his asthma medication 10 days ago.  He has been intubated twice in the past 6 months due to severe asthma exacerbations.  On physical examination, his temperature is 37.2 C (99 F), blood pressure is 142/64 mm Hg, heart rate is 110/min, and respirations are 28/min.  His oxygen saturation is 84% on room air and improves to 94% on nonrebreather mask.  The patient is alert but appears to be in respiratory distress with some use of accessory muscles of respiration.  His lung examination shows equal, bilateral air entry with diffuse wheezing throughout both lung fields.  His peak expiratory flow rate is 60% of his personal best, based on his prior admissions. 
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c074_9946_8f63_1b2f766569d3_MD0005_00 Early treatment of acute asthma exacerbation is crucial in preventing significant morbidity and mortality. Severity of airflow limitation is assessed using peak expiratory flow (PEF). PEF (40%-69% of baseline) is considered a mild to moderate exacerbation. These patients should be started on inhaled short- acting beta agonists (SABA) for rapid correction of bronchospasm. Patients with PEF <40% should receive high-dose SABA with ipratropium. Serial PEF measurements are used to assess response to treatment. Major side effects of SABA are tachycardia and tremors. Tachycardia in asthma exacerbation is due to hypoxia, which stimulates carotid chemoreceptors to increase catecholamine secretion from the adrenal medulla. Correction of bronchospasm to improve ventilation and hypoxia is most effectively achieved with SABA. Therefore, pre-existing tachycardia is not a contraindication to SABA use. (Choice A) Parenteral magnesium sulfate is a bronchodilator. It is indicated when the PEF is <40% despite >1 hour of intensive therapy with inhaled SABA and glucocorticoids. It has not been shown to benefit patients with mild to moderate exacerbations. (Choice B) Patients with acute asthma exacerbation are at risk of deterioration and respiratory failure. They should be monitored in the hospital to assess response to therapy. Patients with moderate exacerbation who have sustained (>1 hour) improvement in PEF to >70% with SABA with or without glucocorticoids may be discharged from the emergency department. (Choice D) Systemic corticosteroids should also be administered early in the treatment of acute asthma exacerbation. Because their effect is usually not apparent in the first few hours, SABA should be used concomitantly. (Choice E) Intravenous theophylline is not effective in acute asthma exacerbations. It may worsen tachyrhythmias, particularly when combined with beta agonists. Educational objective: Peak expiratory flow is <40% of baseline in severe asthma exacerbation and 40%-69% in mild to moderate asthma exacerbation. Inhaled short-acting beta agonists are the first-line treatment regardless of severity. Inhaled ipratropium should also be given with beta agonists in severe asthma exacerbation. References: Expert Panel Report 3: guidelines for the diagnosis and management of asthma - summary report 2007. (http://www.ncbi.nlm.nih.gov/pubmed/17983880) Guideline for the management of acute asthma in adults: 2013 update. (http://www.ncbi.nlm.nih.gov/pubmed/23656743)

Question 14

A 46-year-old man comes to the office due to a 3-day history of cough, wheezing, and shortness of breath.  Symptoms started a week ago with nasal congestion, sore throat, and body aches.  The cough is productive of thin, whitish sputum.  The patient has no fever, chills, chest pain, or abdominal pain.  He has asthma managed with budesonide-formoterol as needed.  Since yesterday, he has used the inhaler multiple times without significant symptom relief.  His other medical condition is hypertension.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 138/74 mm Hg, pulse is 86/min, and respirations are 20/min.  Pulse oximetry is 96% on room air.  The patient speaks in full sentences.  He appears mildly uncomfortable but does not use accessory respiratory muscles.  Jugular venous pressure is normal.  There is no nasal sinus tenderness. The pharyngeal mucosa is without exudates.  Bilateral expiratory wheezing with prolonged expiration is noted.  Inspiratory breath sounds are normal.  Heart sounds are normal.  Peak expiratory flow is 30% lower than his prior baseline.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient with 3 days of cough, wheezing, and shortness of breath has an acute asthma exacerbation, defined as an increase in asthma symptoms (eg, cough, dyspnea, wheezing) combined with a >20% reduction in peak expiratory flow rate. The most common trigger is viral upper respiratory infection, which is suggested by this patient's recent nasal congestion, sore throat, and myalgia. Several published treatment guidelines recommend the use of systemic corticosteroids for: Mild exacerbations in the outpatient setting that have been unresponsive to standard inhaler therapy (eg, no improvement despite increasing inhaled corticosteroid-formoterol as needed use, as in this patient). All moderate to severe acute asthma exacerbations in the urgent care or emergency department. Emergency medical care is necessary for patients with severe symptoms (eg, hypoxemia, difficulty speaking, use of accessory muscles, reduction in peak expiratory flow >50% from baseline); however, those with mild symptoms, such as this patient, can be treated on an outpatient basis (Choice E). Patients treated promptly with a short course of systemic corticosteroids have fewer future exacerbations requiring hospitalization and have improved long-term asthma control. The optimal dosage and duration of corticosteroid therapy are not strictly defined; however, general recommendations are prednisone 40-60 mg daily for 5-10 days. (Choice A) Inhaled, long-acting muscarinic antagonists (LAMAs) (eg, tiotropium) are chronic controller agents recommended for asthma step-up therapy in patients with inadequate response to a scheduled inhaled corticosteroid and beta agonist. They are not used to treat acute exacerbations. LAMA monotherapy is preferred as initial treatment for most patients with chronic obstructive pulmonary disease (COPD). asthma step-up therapy (Choice B) Chest x-rays are not routinely obtained during an asthma exacerbation unless there is evidence of a superimposed cardiopulmonary condition such as pneumonia (eg, fever, purulent sputum, crackles, egophony). Nasal congestion, mildly productive cough, and myalgia are consistent with a viral upper respiratory infection; in this situation, chest x-ray would likely be unrevealing. (Choice C) Macrolide antibiotics (eg, azithromycin) are beneficial for certain patients with acute exacerbations of COPD, partially because they dampen neutrophil-mediated airway inflammation. In multiple clinical trials, macrolides had no benefit for acute asthma exacerbations, which are driven by eosinophil-mediated airway inflammation. Educational objective: A short course of systemic corticosteroids is indicated for outpatient treatment of patients with mild acute asthma exacerbations unresponsive to bronchodilator therapy. It reduces the need for hospitalization and improves long-term control. Prednisone 40-60 mg daily for 5-7 days is a widely adopted regimen. References: Treatment for acute asthma in the emergency department: practical aspects. (http://www.ncbi.nlm.nih.gov/pubmed/20391960) Management of acute asthma exacerbations. (http://www.ncbi.nlm.nih.gov/pubmed/21766754)

Question 15

A 67-year-old man comes to the emergency department due to cough with greenish sputum production and increased shortness of breath over the last 4 days. His medical history includes chronic obstructive pulmonary disease treated with tiotropium and budesonide/formoterol. The patient reports increased use of albuterol to 4 times a day. Two months ago, his FEV1 to FVC ratio was 55% of predicted and diffusing capacity of the lungs for carbon monoxide was within normal limits. Today, the patient's blood pressure is 152/90 mm Hg, pulse is 108/min, respirations are 22/min, and pulse oximetry shows 88% on room air. He is in mild respiratory distress with some accessory muscle usage and can speak in short sentences. Chest auscultation reveals prolonged expiration with bilateral wheezes. Arterial blood gas on room air shows pH 7.35, PaCO₂ 44 mm Hg, and PaO₂ 55 mm Hg. Pulse oximetry improves to 95% after he is placed on supplemental oxygen at 5 L/min. Which of the following mechanisms best explains this patient's improvement in oxygen saturation following oxygen supplementation?

Accepted Answer

Explanation: Hypoxemia in chronic obstructive pulmonary disease (COPD) is primarily caused by ventilation/perfusion (V/Q) mismatch. The emphysematous component of COPD causes airflow limitation due to loss of elastic tissue and small bronchiolar collapse, and chronic bronchitis contributes to airflow limitation as well. COPD exacerbation causes further airflow limitation due to mucus plugging and bronchospasm. The result is numerous localized areas of lung that have a low V/Q ratio, which is the major cause of hypoxemia in patients with COPD. These poorly ventilated lung regions (low V/Q regions) undergo hypoxic vasoconstriction to improve overall gas exchange efficiency, but nonetheless still have a low V/Q ratio. Despite restricted airflow, supplemental oxygen (O₂) is able to successfully reach the alveoli in these regions, resulting in an increase in Q (due to alleviation of hypoxic vasoconstriction) and improved gas exchange to the blood (improved hypoxemia). Emphysema also leads to areas of lung that have a high V/Q ratio (dead space ventilation) due to destruction of the alveolar-capillary interface, but these regions play a relatively minor role in hypoxemia and are more important in the development of hypercapnia. Supplemental O₂ also increases V in high V/Q lung regions; however, as Q does not increase significantly (and the O₂-carrying capacity of existing Q is essentially maxed out), the ability to improve hypoxemia from these regions is minimal (Choice C). (Choice A) Right-to-left anatomic shunts (eg, cyanotic congenital heart disease) bypass normal pulmonary capillary beds. Because blood is never delivered to the alveoli, increasing alveolar O₂ content will not alter systemic oxygenation. (Choice B) Increased fraction of inspired O₂ increases the O₂ partial pressure gradient across the alveolar-pulmonary capillary membrane, resulting in increased diffusing capacity of the lung for O₂. However, the effects on hypoxemia are minimal compared to those of improved V/Q mismatch. (Choice E) When O₂ binds to hemoglobin, it promotes the release of carbon dioxide from hemoglobin (Haldane effect); however, the effect on hypoxemia of increased off-loading of carbon dioxide is not significant. Haldane effect Educational objective: Ventilation/perfusion (V/Q) mismatch in low V/Q lung regions is the major cause of hypoxemia in patients with chronic obstructive pulmonary disease, and the mismatch is worsened during exacerbation. Supplemental oxygen improves hypoxemia in these patients primarily by increasing oxygen exchange in lung regions that have a low V/Q ratio. References: Gas exchange and ventilation-perfusion relationships in the lung. (http://www.ncbi.nlm.nih.gov/pubmed/25063240) Hypoxemia in patients with COPD: cause, effects, and disease progression. (http://www.ncbi.nlm.nih.gov/pubmed/21660297)

Question 16

A 72-year-old man is evaluated in his hospital room for hypoxemia and shortness of breath. He says, "I just can't seem to get enough air to breathe." He also has a cough that is intermittently productive of white sputum. The patient underwent emergency open colectomy 3 days ago for cecal volvulus. His course was complicated by postoperative respiratory failure, and he remained on a mechanical ventilator for 48 hours. He was extubated 12 hours ago and has since had significant pain around the incision site, receiving opioid medications as needed. Medical history includes hypertension, ischemic stroke with resulting left-sided weakness, and coronary artery disease. The patient has smoked a pack of cigarettes a day for the last 45 years. He has no history of alcohol or drug abuse. Temperature is 37 C (98.6 F), blood pressure is 145/90 mm Hg, pulse is 90/min, and respirations are 24/min. Oxygen saturation is 87% on room air. The patient appears chronically ill and drowsy. Examination shows moist mucous membranes and normal jugular venous pressure. Respirations are shallow and limited by pain around the incision. The patient has a weak cough with no stridor. Breath sounds are diminished at the bilateral lung bases, with scattered rhonchi. Heart sounds are normal. The abdomen is mildly distended and tender near the incision site. The surgical wound appears clean and is without discharge. There is 1+ bilateral edema of the lower extremities. A complete blood count and metabolic panel are normal. Arterial blood gas analysis on room air shows a pH of 7.47, PaO₂ of 56 mm Hg, and PaCO₂ of 33 mm Hg. Chest x-ray reveals small lung volumes and bilateral linear densities of the lower lobe. In addition to the supplemental oxygen to correct the hypoxemia, which of the following is most beneficial for treating this patient's respiratory symptoms?

Accepted Answer

Explanation: 11ec2b69_c077_0a49_8f63_b54648cc223c_MD0005_00 Postoperative atelectasis is common following thoracoabdominal surgeries; it results from decreased lung compliance (a transient effect of thoracoabdominal surgery possibly due to anesthesia) as well as postoperative pain leading to hypoventilation, reduced cough, and impaired mucus clearance. Smoking, obesity, and underlying lung or neurologic disease increase the risk of postoperative atelectasis. The manifestations are usually somewhat delayed, typically occurring 2-5 days postoperatively; when symptomatic, patients may have increased work of breathing or hypoxemia. Arterial blood gas results typically reveal an increased alveolar-arterial gradient due to intrapulmonary shunting. Chest x-ray characteristically shows linear opacifications in the bilateral lung bases, sometimes with an accompanying shift of structures toward the opacification (if the atelectasis is large). For patients with minimal respiratory secretions, the administration of continuous positive airway pressure (CPAP) is often effective. However, those with more copious secretions (such as this patient with cough productive of white sputum) are most appropriately managed with aggressive pulmonary hygiene, including chest physiotherapy and suctioning, rather than CPAP. (Choice A) Ceftriaxone with azithromycin is appropriate for community-acquired pneumonia. However, the absence of fever and consolidation on chest x-ray in this patient make pneumonia unlikely. In addition, postoperative pneumonia is often caused by relatively resistant hospital-acquired pathogens; when the diagnosis is suspected, empiric treatment should include an antipseudomonal agent (eg, piperacillin-tazobactam). (Choice C) Opioids cause central respiratory depression, which can lead to hypoventilation and can contribute to atelectasis. Although minimizing the dose of opioid medication is appropriate for preventing further atelectasis in this patient, aggressive pulmonary hygiene is the most effective therapeutic intervention. (Choice D) Diuresis with intravenous furosemide is appropriate for pulmonary edema due to volume overload. Although this patient has bilateral edema of the lower extremities, the absence of jugular venous distension and pleural effusion or bibasilar alveolar infiltrates on chest x-ray make significant pulmonary edema unlikely. (Choice E) Scheduled nebulized bronchodilators are used to treat bronchospasm, a common postoperative complication that typically occurs early in the postoperative period. The absence of wheezing on physical examination makes bronchospasm less likely in this patient. Educational objective: Postoperative atelectasis is common 2-5 days following thoracoabdominal surgery and typically presents with hypoxemia or respiratory difficulty. Patients without respiratory secretions can be managed with continuous positive airway pressure, whereas those with secretions are best managed with aggressive pulmonary hygiene, including chest physiotherapy and suctioning. References: Mechanisms of atelectasis in the perioperative period. (http://www.ncbi.nlm.nih.gov/pubmed/20608554) Postoperative pulmonary complications after noncardiothoracic surgery. (http://www.ncbi.nlm.nih.gov/pubmed/26556919)

Question 17

A 16-year-old boy comes to the office for follow-up after having been seen in the emergency department 5 days ago due to an acute asthma exacerbation.  Two weeks ago, he developed a cough and rhinorrhea.  The rhinorrhea resolved after a few days, but the cough worsened and he began wheezing, prompting his visit to the emergency department.  In the emergency department, his temperature was 36.7 C (98 F), respirations were 24/min, pulse oximetry was 94% on room air, and pulmonary examination revealed scattered expiratory wheezes with slightly diminished breath sounds in all fields.  The patient received 2 doses of nebulized albuterol and 60 mg of oral prednisone, after which he felt considerably better and had a normal lung examination; he was then discharged home on an additional 60 mg of prednisone daily for the next 4 days.  Today he feels well and his cardiopulmonary examination is normal.  Prior to this illness, he had been treated at home for the last several years with intermittent albuterol.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c075_83a8_8f63_f3a4569da00d_MD0005_00 Oral glucocorticoids (GCs) are the standard of care for treatment of acute asthma exacerbations refractory to bronchodilator therapy. GCs help alleviate airway inflammation and airflow obstruction. However, the duration of therapy should be as short as possible due to potential adverse effects. Exogenous GCs suppress endogenous cortisol production through negative feedback on the hypothalamic-pituitary-adrenal (HPA) axis. This suppression of the HPA axis may lead to adrenal insufficiency on discontinuation of glucocorticoids depending on the dose and duration of therapy. HPA axis suppression is more likely with prolonged (>3 weeks) GC usage, especially at higher doses or with evening administration. In these cases, a gradual taper of GCs is indicated to allow for the return of adequate endogenous cortisol production (Choice B). suppression of the HPA axis By contrast, short-term (<3 weeks) use of GCs is unlikely to cause significant suppression of the HPA axis, and GCs can be stopped abruptly with minimal risk of significant adrenal insufficiency. This patient has had only a 5-day course of systemic GCs and may safely discontinue without tapering. (Choices C and E) A lengthy taper of >1 month may be required for patients with very prolonged GC therapy (eg, >1 year). Alternate-day GC dosing may be associated with decreased suppression of the HPA axis and reduce the need for tapering. This patient has an acute asthma exacerbation that is now resolved; he requires neither additional treatment with GCs nor a taper of medication. (Choice D) Extending the high-dose GC regimen could be considered for a patient whose symptoms have improved but not resolved after an initial 5-day course; a taper would still not be indicated for a patient with 10 days of therapy. This patient's acute asthma exacerbation is resolved; therefore, he does not require additional GC therapy. Educational objective: Glucocorticoid administration for <3 weeks does not typically cause significant suppression of the hypothalamic-pituitary-adrenal axis and can be stopped abruptly with minimal risk of adrenal insufficiency. References: Glucocorticoid therapy and adrenal suppression. (http://www.ncbi.nlm.nih.gov/pubmed/25905379)

Question 18

A 68-year-old man with chronic obstructive pulmonary disease (COPD) comes to the clinic due to a 9-kg (20-lb) weight loss over the last 2 years. He describes his appetite as "all right" but does say that he is eating less. The patient reports poor taste, fatigue, chronic dyspnea, productive cough, and occasional nausea. He also reports insomnia most nights of the week with poor concentration during the day. He has no night sweats, fevers, chills, dysphagia, change in bowel habits, blood in the stool, or dysphoria. He has had 3 hospitalizations for COPD exacerbation over the past 2 years during which he was treated with short courses of prednisone. The patient has smoked 2 packs of cigarettes daily for 42 years. He reports feeling "bad" for smoking all these years and is trying to quit but says, "It's just very hard." The patient lives alone and often feels lonely. His other medical problems include hypertension and hyperlipidemia. His last colonoscopy was 5 years ago and included removal of 2 hyperplastic polyps. He does not use alcohol or recreational drugs. Family history is not significant. Temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 18/min. BMI is 17 kg/m². Pulse oximetry shows 91% on ambient air. Physical examination reveals moist mucous membranes, normal jugular venous pressure, and distant S1 and S2. Lung examination reveals prolonged expiration, increased resonance to percussion bilaterally, and increased anterior-to-posterior diameter of the chest. The abdomen is soft and nontender. There is no hepatomegaly, splenomegaly, or masses. Testing of the stool for occult blood is negative. No edema or lymphadenopathy is present. Neurologic examination is within normal limits. The patient's affect is normal. Laboratory results are as follows: Chest x-ray reveals hyperexpansion of bilateral lung fields with diaphragmatic flattening. Which of the following is the most likely cause of this patient's weight loss?

Accepted Answer

Explanation: This patient's weight loss is likely due to pulmonary cachexia syndrome (PCS), a phenomenon of loss of lean muscle mass associated with chronic lung disease, namely chronic obstructive pulmonary disease (COPD). BMI <20 kg/m² or weight loss >5% is often used to suggest the disorder. PCS occurs in 20%-40% of patients with COPD and leads to impaired balance, increased susceptibility to lung infections, and increased mortality. Development of the disorder correlates with disease severity, and it is most commonly seen in patients with severe COPD. The mechanisms responsible for PCS are likely multifactorial and include the following: Increased work of breathing causes increased caloric use, resulting in significant energy imbalance in the setting of the decreased appetite and low dietary intake typically present in patients with advanced COPD. Systemic inflammation likely plays a role by contributing to decreased appetite and catalyzing skeletal muscle breakdown. Skeletal muscle hypoxia and, in some patients, glucocorticoid use likely also contribute. Treatment of PCS involves optimization of lung function, exercise, and nutritional supplementation. (Choice A) Adrenal insufficiency (AI) is characterized by weight loss, fatigue, hypotension, bradycardia, and hypoglycemia. Iatrogenic AI can occur in patients who rapidly stop moderate or high-dose prednisone therapy of >3 weeks, but it is rare in those taking intermittent, short courses of prednisone (eg, for occasional COPD exacerbation). In addition, the absence of hypotension and bradycardia in this patient makes AI less likely. (Choice C) Colon cancer is a potential cause of weight loss that takes years to develop. It is very unlikely in this patient with a colonoscopy 5 years ago that revealed only hyperplastic (nonpremalignant) polyps. (Choice D) This patient has symptoms consistent with major depressive disorder (eg, insomnia, fatigue, decreased dietary intake, impaired concentration). However, a number of these findings are explained by severe COPD (eg, fatigue, early satiety due to diaphragmatic flattening), which is a more likely cause of his weight loss. (Choice E) Reactivation or secondary tuberculosis occurs due to weakening of the immune system in patients with latent tuberculosis. Weight loss is common, but absence of fever, night sweats, and upper lobe infiltrates or cavitation on chest x-ray makes the diagnosis unlikely. Educational objective: Severe chronic obstructive pulmonary disease is commonly accompanied by pulmonary cachexia syndrome, which is characterized by loss of lean muscle mass due to energy imbalance and systemic inflammation. References: Possible mechanisms underlying the development of cachexia in COPD. (http://www.ncbi.nlm.nih.gov/pubmed/18310396) Factors contributing to muscle wasting and dysfunction in COPD patients. (http://www.ncbi.nlm.nih.gov/pubmed/18229567)

Question 19

A 6-month-old boy is brought to the emergency department by his mother during the winter due to 3 days of nasal discharge and cough.  His mother states, "He hasn't been breastfeeding well today because he's so congested."  The infant has been voiding adequately and has had no vomiting, diarrhea, or skin rash.  His older brother attends preschool and is recovering from an upper respiratory illness.  The patient has no prior illnesses and no known allergies, and all vaccinations are up to date.  He was born at term via an uncomplicated delivery and has met all developmental milestones appropriately.  Temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, pulse is 150/min, and respirations are 50/min.  Pulse oximetry shows an oxygen saturation of 93% on room air.  Examination reveals moderate respiratory distress with subcostal retractions, coarse breath sounds, and expiratory wheezing bilaterally.  Oral mucous membranes are dry, but capillary refill is <2 seconds.  The patient is admitted to the hospital and placed on appropriate infection-control precautions. 
Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: This patient's clinical presentation is most consistent with bronchiolitis, an infection that occurs in the winter and is most commonly caused by respiratory syncytial virus (RSV). Patients typically have nasal congestion, rhinorrhea, coarse breath sounds, and wheezing with or without crackles. Other common features include a low-grade fever, increased work of breathing with accessory muscle use (eg, retractions), nasal flaring, and grunting. Respiratory symptoms may interfere with feeding and increase the risk of dehydration. Patients with respiratory distress, apnea, hypoxia, and/or dehydration should be hospitalized on contact and droplet precautions to prevent nosocomial spread of this extremely contagious virus. Therapy generally consists of supportive measures, such as intravenous fluids, nasal bulb suctioning, and/or humidified oxygen. Inhaled bronchodilators used to be recommended, but this is no longer the case as current evidence shows that they do not reduce illness duration, admission rates, or length of hospital stay. (Choice A) Antibiotics have no role in the treatment of bronchiolitis unless there is concern for coexisting bacterial pneumonia (eg, high fever, focal crackles on auscultation, consolidation on chest x-ray). (Choice B) Nebulized hypertonic saline has not been shown to improve clinical outcomes or to reduce length of hospital stay. Hypertonic saline can also induce bronchospasm, and it is not recommended in the routine care of patients with bronchiolitis. (Choice C) Although ribavirin has in vitro activity against RSV, it is extremely expensive and has no proven benefit in most children. It is usually reserved for immunocompromised patients with severe disease. In addition, the absence of fever in this patient makes RSV bronchiolitis more likely than influenza; therefore, treatment with oseltamivir is unwarranted. (Choice D) Systemic corticosteroids are not recommended for first-time bronchiolitis due to the lack of evidence of clinical effect. Corticosteroids can be considered in patients with recurrent wheezing or asthma exacerbation. Educational objective: Bronchiolitis is a lower respiratory tract infection occurring during the winter and is caused primarily by respiratory syncytial virus. Infants with moderate to severe respiratory distress or dehydration may require hospitalization. Supportive care is the mainstay of treatment. References: Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/22473882) Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. (http://www.ncbi.nlm.nih.gov/pubmed/25349312)

Question 20

A 55-year-old man comes to the emergency department after coughing up blood earlier this morning.  The patient estimates that he coughed up 100 mL of blood at home and another 50 mL in the emergency department.  He reports 4 hospital admissions for pneumonia in the past 18 months, but this is the first episode of hemoptysis.  He has a chronic cough with yellow-green sputum production that is sometimes foul-smelling.  The patient gets winded after climbing 2 flights of stairs or walking uphill.  He is an ex-smoker with a 10-pack-year history.  Physical examination is notable for crackles at the right lung base and scattered bilateral wheezes.  There is no jugular venous distension or lower-extremity edema.  What is the most likely mechanism of hemoptysis in this patient?

Accepted Answer

Explanation: 11ec2b69_c077_cd9a_8f63_d5325cebb408_MD0005_00 Recurrent infections and daily cough with mucopurulent sputum production are suggestive of bronchiectasis. Damage to the bronchial walls from infection (such as pneumonia in this patient) or inflammation predisposes to repeated infections, setting up a cycle of further airway damage and recurrent infection. The chronic airway inflammation and edema can lead to rupture of superficial blood vessels and cause hemoptysis. Pulmonary infections overall are the most common cause of hemoptysis, accounting for up to 70% of cases. (Choice A) Granulomatosis with polyangiitis (formerly Wegener's granulomatosis) can cause chronic rhinosinusitis and present with hemoptysis, but it most commonly presents with constitutional symptoms such as fever and migratory arthralgias. (Choice B) Mitral stenosis or left heart failure can raise pulmonary capillary pressure, causing hemoptysis. Patients with congestive heart failure are likely to have bilateral (rather than unilateral) basal crackles from pulmonary edema, jugular venous distension, and possibly lower-extremity edema. (Choice C) Chest radiography is important to rule out malignancy in patients with hemoptysis. However, copious sputum production with recurrent infections is highly suggestive of bronchiectasis. In addition, this patient's age and relatively limited tobacco exposure make this diagnosis less likely. (Choice E) Chronic cough alone does not cause hemoptysis, and this patient has no other signs of coagulopathy. Educational objective: Hemoptysis is frequently caused by pulmonary infection, which may be chronic or acute. The chronic inflammation and localized edema associated with bronchiectasis predispose to blood vessel infiltration and rupture. References: Hemoptysis: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/16225028)

Exam 1: Advanced Clinical Medicine